Healthcare Provider Details

I. General information

NPI: 1922921147
Provider Name (Legal Business Name): MARISSA MAATALLAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 GEORGIA AVE SE STE 206
ATLANTA GA
30312-3000
US

IV. Provider business mailing address

9105 BRIXWORTH PL NE
BROOKHAVEN GA
30319-5336
US

V. Phone/Fax

Practice location:
  • Phone: 404-653-0374
  • Fax: 404-653-0375
Mailing address:
  • Phone: 601-941-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: