Healthcare Provider Details

I. General information

NPI: 1205516754
Provider Name (Legal Business Name): TAHEISHA RENA DEESE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 HIGHWAY 54 W STE 305
FAYETTEVILLE GA
30214-4537
US

IV. Provider business mailing address

155 BUCKEYE LN
FAYETTEVILLE GA
30214-1702
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-5660
  • Fax:
Mailing address:
  • Phone: 229-425-8130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN165350
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberRN165350
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: