Healthcare Provider Details

I. General information

NPI: 1912341975
Provider Name (Legal Business Name): STEPHANIE SHIREEN GREGORY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3747 ROSWELL RD STE 201
MARIETTA GA
30062-6227
US

IV. Provider business mailing address

3747 ROSWELL RD STE 201
MARIETTA GA
30062-6227
US

V. Phone/Fax

Practice location:
  • Phone: 470-956-1590
  • Fax:
Mailing address:
  • Phone: 470-956-1590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number81982
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number81982
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: