Healthcare Provider Details

I. General information

NPI: 1215904446
Provider Name (Legal Business Name): DEANANNE D FORDHAM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: DEANANNE DEES PAC

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 PLAZA AVE
EASTMAN GA
31023-6763
US

IV. Provider business mailing address

RR 1 BOX 60
CHESTER GA
31012-9501
US

V. Phone/Fax

Practice location:
  • Phone: 478-374-3814
  • Fax: 478-374-1478
Mailing address:
  • Phone: 478-358-9436
  • Fax: 478-374-1478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003393
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: