Healthcare Provider Details

I. General information

NPI: 1750945044
Provider Name (Legal Business Name): AYESHA AMEERAH AFRAH BAKER HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 WHITEHALL ST SW
ATLANTA GA
30303-3721
US

IV. Provider business mailing address

3645 MARKETPLACE BLVD STE 130-490
EAST POINT GA
30344-5747
US

V. Phone/Fax

Practice location:
  • Phone: 678-365-3022
  • Fax:
Mailing address:
  • Phone: 678-508-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO104171
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: