Healthcare Provider Details

I. General information

NPI: 1124237961
Provider Name (Legal Business Name): TARAYN ALESSANDRA FAIRLIE MD MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARAYN ALESSANDRA GRIZZARD

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 STEVE REYNOLDS BLVD. KAISER PERMANENTE GWINNETT MEDICAL CENTER
DULUTH GA
30096
US

IV. Provider business mailing address

3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 770-931-6010
  • Fax:
Mailing address:
  • Phone: 404-364-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number067870
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: