Healthcare Provider Details

I. General information

NPI: 1639349764
Provider Name (Legal Business Name): SANDI JACQUELYN STEPHENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 W PONCE DE LEON AVE SUITE 7
DECATUR GA
30030-2458
US

IV. Provider business mailing address

795 KELLS RIDGE DR
ELLIJAY GA
30540-2353
US

V. Phone/Fax

Practice location:
  • Phone: 404-964-1072
  • Fax:
Mailing address:
  • Phone: 404-964-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number004092
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: