Healthcare Provider Details

I. General information

NPI: 1902425473
Provider Name (Legal Business Name): MEGAN RAYNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FERRY RD
ATLANTA GA
30342-1605
US

IV. Provider business mailing address

643 CARLETON TRL
BEL AIR MD
21014-2854
US

V. Phone/Fax

Practice location:
  • Phone: 443-307-7234
  • Fax:
Mailing address:
  • Phone: 443-307-7234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95853
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: