Healthcare Provider Details

I. General information

NPI: 1811375231
Provider Name (Legal Business Name): MEGHANN DAVIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 VIRGINIA AVE
ATLANTA GA
30354-1326
US

IV. Provider business mailing address

2954 GATEWAY AVE
MACON GA
31211-2660
US

V. Phone/Fax

Practice location:
  • Phone: 404-762-1001
  • Fax:
Mailing address:
  • Phone: 478-733-6426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberPTA0002771
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: