Healthcare Provider Details

I. General information

NPI: 1275576191
Provider Name (Legal Business Name): LAURA SUSAN MCCALL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA SUSAN SPEIDEL PAC

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 GENTILLY BLVD
CARTERSVILLE GA
30120-8522
US

IV. Provider business mailing address

150 GENTILLY BLVD
CARTERSVILLE GA
30120-8522
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-6670
  • Fax:
Mailing address:
  • Phone: 470-490-6670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12304
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000548A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: