Healthcare Provider Details

I. General information

NPI: 1932497567
Provider Name (Legal Business Name): JYOTHSNA S CHALLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PONCE DE LEON AVE
DECATUR GA
30030-3466
US

IV. Provider business mailing address

200 E PONCE DE LEON AVE
DECATUR GA
30030-3466
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-6363
  • Fax:
Mailing address:
  • Phone: 404-501-6363
  • Fax: 404-371-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6131
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6131
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: