Healthcare Provider Details

I. General information

NPI: 1598133548
Provider Name (Legal Business Name): VIRGINIA LYNN BALKCOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

IV. Provider business mailing address

1500 CONCORD TER FL 5
SUNRISE FL
33323-2815
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-1745
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number7723
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: