Healthcare Provider Details

I. General information

NPI: 1851913651
Provider Name (Legal Business Name): GRACE ASHLEY BUSHONG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE ASHLEY HENDERSON PA

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CHERRY ST NE
MARIETTA GA
30060-7205
US

IV. Provider business mailing address

3127 ROCK PORT CIR
NORCROSS GA
30092-2742
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-5700
  • Fax:
Mailing address:
  • Phone: 678-906-9334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: