Healthcare Provider Details

I. General information

NPI: 1700573730
Provider Name (Legal Business Name): NELLIENA SIMONE YOUNG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 KENT RD STE 5
TIFTON GA
31794-1697
US

IV. Provider business mailing address

PO BOX 2650
TIFTON GA
31793-2650
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-7337
  • Fax: 229-391-4051
Mailing address:
  • Phone: 229-402-0425
  • Fax: 229-391-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number111898
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: