Healthcare Provider Details

I. General information

NPI: 1851455133
Provider Name (Legal Business Name): PERMELIA ANN PARKER CSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2359 NOEL C CONAWAY RD
GUYTON GA
31312-6114
US

IV. Provider business mailing address

PO BOX 471
BLOOMINGDALE GA
31302-0471
US

V. Phone/Fax

Practice location:
  • Phone: 912-728-6753
  • Fax:
Mailing address:
  • Phone: 912-728-6753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number04-228
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: