Healthcare Provider Details

I. General information

NPI: 1467623363
Provider Name (Legal Business Name): SUSAN CAPITAN SEXTON NCTMB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 CHURCH ST NE
MARIETTA GA
30060-1358
US

IV. Provider business mailing address

1766 APPLE BLVD
MARIETTA GA
30066-2955
US

V. Phone/Fax

Practice location:
  • Phone: 770-519-7778
  • Fax:
Mailing address:
  • Phone: 770-579-5868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4587
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: