Healthcare Provider Details

I. General information

NPI: 1992966501
Provider Name (Legal Business Name): KRISTEN PAYNE DEWEESE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 E WALNUT AVE
DALTON GA
30721-8724
US

IV. Provider business mailing address

2918 E WALNUT AVE
DALTON GA
30721-8724
US

V. Phone/Fax

Practice location:
  • Phone: 706-529-4600
  • Fax: 706-529-4633
Mailing address:
  • Phone: 706-529-4600
  • Fax: 706-529-4633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number65874
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1177LL
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: