Healthcare Provider Details

I. General information

NPI: 1619596293
Provider Name (Legal Business Name): TAYLOR LYNN HEACOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 BROOKSIDE PKWY STE 105
ALPHARETTA GA
30022-4457
US

IV. Provider business mailing address

5780 PEACHTREE DUNWOODY RD STE 300
ATLANTA GA
30342-1513
US

V. Phone/Fax

Practice location:
  • Phone: 770-751-3600
  • Fax: 770-751-3615
Mailing address:
  • Phone: 404-303-8035
  • Fax: 404-303-1325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number100050
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: