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NPI Code Detail

MEDICARE: JA NA MONIQUE HOLYFIELD PA

MEDICARE: JA NA MONIQUE HOLYFIELD PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant8078GA

General Provider Information

NPI Number : 1356300651
Entity Type Code : Individual
Provider Name (Legal Business Name) : JA NA MONIQUE HOLYFIELD PA
Provider Business Mailing Address
First Line : 211 FAIRVIEW RD
Second Line :
City : ELLENWOOD
State : GA
Zip : 30294-2721
Country : US
Telephone Number : 678-289-6747
Fax Number : 678-289-6750
Provider Business Practice Location Address
First Line : 211 FAIRVIEW RD
Second Line :
City : ELLENWOOD
State : GA
Zip : 30294-2721
Country : US
Telephone Number : 678-289-6747
Fax Number : 678-289-6750
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/23/2006
Last Update Date : 03/17/2018

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