Healthcare Provider Details

I. General information

NPI: 1144406786
Provider Name (Legal Business Name): PATRICE LEONIE BASANTA-HENRY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 11/30/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 BEAVER RUIN RD NW SUITE D
LILBURN GA
30047-3401
US

IV. Provider business mailing address

625 BEAVER RUIN RD NW SUITE D
LILBURN GA
30047-3401
US

V. Phone/Fax

Practice location:
  • Phone: 770-279-3838
  • Fax:
Mailing address:
  • Phone: 770-279-3838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number000368
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number60556
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: