Healthcare Provider Details

I. General information

NPI: 1356314157
Provider Name (Legal Business Name): MELANIE VICKERY STANLEY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 BEDGOOD AVE
ARABI GA
31712
US

IV. Provider business mailing address

PO BOX 5007
CORDELE GA
31010
US

V. Phone/Fax

Practice location:
  • Phone: 229-273-0116
  • Fax: 229-273-4853
Mailing address:
  • Phone: 229-271-4656
  • Fax: 229-271-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002127
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: