Healthcare Provider Details

I. General information

NPI: 1295302859
Provider Name (Legal Business Name): DR. SRI RASMITA JALLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 AUSTELL RD
AUSTELL GA
30106-1844
US

IV. Provider business mailing address

7995 CAVENDISH PL
SUWANEE GA
30024-1571
US

V. Phone/Fax

Practice location:
  • Phone: 678-460-2700
  • Fax:
Mailing address:
  • Phone: 678-672-7988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12986
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number110804
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: