Healthcare Provider Details

I. General information

NPI: 1669034567
Provider Name (Legal Business Name): MELISSA VIOLETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

2755 PRINCETON TRCE
CUMMING GA
30041-2860
US

V. Phone/Fax

Practice location:
  • Phone: 860-874-4265
  • Fax:
Mailing address:
  • Phone: 860-874-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number9436
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: