Healthcare Provider Details

I. General information

NPI: 1942564844
Provider Name (Legal Business Name): MARCELLA EDWARDS FORD NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 HISTORIC HIGHWAY 441 N.
DEMOREST GA
30535
US

IV. Provider business mailing address

16011 KAIROS RD STE 300
SOUTH CHESTERFIELD VA
23834-5207
US

V. Phone/Fax

Practice location:
  • Phone: 706-754-4348
  • Fax:
Mailing address:
  • Phone: 804-330-4021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN089263
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: