Healthcare Provider Details

I. General information

NPI: 1043046055
Provider Name (Legal Business Name): HAILEY BREANA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 N JEFF DAVIS DR STE B
FAYETTEVILLE GA
30214-1670
US

IV. Provider business mailing address

176 GRANGE RD
GRIFFIN GA
30224-7419
US

V. Phone/Fax

Practice location:
  • Phone: 877-498-0319
  • Fax:
Mailing address:
  • Phone: 912-425-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberRBT-24-373722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: