Healthcare Provider Details

I. General information

NPI: 1235797291
Provider Name (Legal Business Name): GRACE BECKHAM KNOTTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 GA-34
NEWNAN GA
30265
US

IV. Provider business mailing address

4410 SKYLAND DR NE
ATLANTA GA
30342-3422
US

V. Phone/Fax

Practice location:
  • Phone: 770-502-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9268
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: