Provider Demographics
NPI:1679043913
Name:HYSONS, NORDWANNA VENITE-LUBIN (LPM)
Entity type:Individual
Prefix:MRS
First Name:NORDWANNA
Middle Name:VENITE-LUBIN
Last Name:HYSONS
Suffix:
Gender:F
Credentials:LPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7387 MALENTA CT APT C
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31315-1243
Mailing Address - Country:US
Mailing Address - Phone:941-467-5803
Mailing Address - Fax:
Practice Address - Street 1:7387 MALENTA CT APT C
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31315-1243
Practice Address - Country:US
Practice Address - Phone:941-467-5803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 101Y00000X
GALPN094918164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No164W00000XNursing Service ProvidersLicensed Practical Nurse