Healthcare Provider Details

I. General information

NPI: 1003208679
Provider Name (Legal Business Name): CAMILLE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2015
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 DECATUR ST SE
ATLANTA GA
30303-3201
US

IV. Provider business mailing address

125 DECATUR ST SE
ATLANTA GA
30303-3201
US

V. Phone/Fax

Practice location:
  • Phone: 404-413-4040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberAT002296
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: