MEDICARE: DEIDRA BOBBIEANN BOHANNON

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
1	208000000X	Pediatrics Physician	11295	GA
2	363A00000X	Physician Assistant	11295	GA
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1588245450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRA BOBBIEANN BOHANNON

Provider Business Mailing Address
First Line	:	3885 PRINCETON LAKES WAY SW STE 302
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5590
Country	:	US
Telephone Number	:	404-629-1880
Fax Number	:

Provider Business Practice Location Address
First Line	:	3885 PRINCETON LAKES WAY SW STE 302
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5590
Country	:	US
Telephone Number	:	404-629-1880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2021
Last Update Date	:	10/21/2025

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Directions to “ DEIDRA BOBBIEANN BOHANNON ” Practice Location

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