Healthcare Provider Details

I. General information

NPI: 1578641742
Provider Name (Legal Business Name): AMY OWEN REEVES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY LOUISE OWEN PA-C

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 STILESBORO RD NW STE 220
KENNESAW GA
30152-7742
US

IV. Provider business mailing address

5455 MERIDIAN MARK RD #130
ATLANTA GA
30342
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-8222
  • Fax:
Mailing address:
  • Phone: 404-255-2033
  • Fax: 404-252-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004838
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004838
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number004838
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: