Healthcare Provider Details

I. General information

NPI: 1841382801
Provider Name (Legal Business Name): PATRICIA DIANNE COUSSENS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 BROAD ST
HAWKINSVILLE GA
31036-4818
US

IV. Provider business mailing address

259 BROAD ST
HAWKINSVILLE GA
31036-4818
US

V. Phone/Fax

Practice location:
  • Phone: 478-300-7107
  • Fax: 478-783-3961
Mailing address:
  • Phone: 478-300-7107
  • Fax: 478-205-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number029613
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: