Healthcare Provider Details

I. General information

NPI: 1720659659
Provider Name (Legal Business Name): JAMIE FAXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/11/2023
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 PEACHTREE RD NW STE 515
ATLANTA GA
30309-5219
US

IV. Provider business mailing address

3390 HIGHGATE HILLS DR NE
DULUTH GA
30097-5120
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-1745
  • Fax:
Mailing address:
  • Phone: 770-653-2735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number10726
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: