Healthcare Provider Details

I. General information

NPI: 1558493619
Provider Name (Legal Business Name): LETITIA W PRICE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 OLD NORTON RD SUITE 200
FAYETTEVILLE GA
30215-4872
US

IV. Provider business mailing address

1835 SAVOY DR SUITE 300
ATLANTA GA
30341-1072
US

V. Phone/Fax

Practice location:
  • Phone: 678-817-1117
  • Fax: 678-817-0823
Mailing address:
  • Phone: 770-495-3396
  • Fax: 770-495-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005009
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: