Healthcare Provider Details

I. General information

NPI: 1295566537
Provider Name (Legal Business Name): CIANDRA REGINE CALHOUN BRANCH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5127 JIMMY CARTER BLVD
NORCROSS GA
30093-1619
US

IV. Provider business mailing address

5127 JIMMY CARTER BLVD
NORCROSS GA
30093-1619
US

V. Phone/Fax

Practice location:
  • Phone: 404-564-7007
  • Fax: 404-481-4520
Mailing address:
  • Phone: 404-564-7007
  • Fax: 404-481-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12509
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: