Healthcare Provider Details

I. General information

NPI: 1558720441
Provider Name (Legal Business Name): PONCHITTA RIDLEY-DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 PRYOR RD SW
ATLANTA GA
30315-6410
US

IV. Provider business mailing address

PO BOX 150464
ATLANTA GA
30315-0187
US

V. Phone/Fax

Practice location:
  • Phone: 770-873-8421
  • Fax: 404-763-2250
Mailing address:
  • Phone: 770-873-8421
  • Fax: 404-763-2250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: