Healthcare Provider Details

I. General information

NPI: 1649181819
Provider Name (Legal Business Name): EMMA GRACE PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 RIDGE AVE
MACON GA
31204-1860
US

IV. Provider business mailing address

3431 RIDGE AVE
MACON GA
31204-1860
US

V. Phone/Fax

Practice location:
  • Phone: 706-304-8914
  • Fax:
Mailing address:
  • Phone: 706-304-8914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015943
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: