Healthcare Provider Details

I. General information

NPI: 1437820974
Provider Name (Legal Business Name): BLAKE DARBY BALLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1462 CLIFTON RD NE STE 280
ATLANTA GA
30322-1063
US

IV. Provider business mailing address

675 BURBANK DR SE
SMYRNA GA
30080-1823
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7825
  • Fax:
Mailing address:
  • Phone: 662-425-9377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11576
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number11576
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: