Healthcare Provider Details

I. General information

NPI: 1043793771
Provider Name (Legal Business Name): DANIELLE FRIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2018
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 ASHFORD DUNWOODY RD NE STE 15B
ATLANTA GA
30346-1516
US

IV. Provider business mailing address

3458 MILL BRIDGE DR
MARIETTA GA
30062-5537
US

V. Phone/Fax

Practice location:
  • Phone: 770-800-3353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12645
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003707
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: