Healthcare Provider Details

I. General information

NPI: 1407764483
Provider Name (Legal Business Name): GRACE HALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N DECATUR RD
DECATUR GA
30033-5918
US

IV. Provider business mailing address

707 MCCAUS LN
MILTON GA
30004-6693
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-1000
  • Fax:
Mailing address:
  • Phone: 770-878-7661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: