Healthcare Provider Details

I. General information

NPI: 1386024941
Provider Name (Legal Business Name): DAVIDETTA FREEMAN SFA, CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 ALAMEIN DR
LAWRENCEVILLE GA
30046-2862
US

IV. Provider business mailing address

1473 ALAMEIN DR
LAWRENCEVILLE GA
30046-2862
US

V. Phone/Fax

Practice location:
  • Phone: 678-425-4568
  • Fax: 678-403-0334
Mailing address:
  • Phone: 678-425-4344
  • Fax: 678-403-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number155777
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: