Healthcare Provider Details

I. General information

NPI: 1598227225
Provider Name (Legal Business Name): SUSANNAH RENEE HARVELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 KINGS WAY
VALDOSTA GA
31602-6921
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 229-333-9736
  • Fax:
Mailing address:
  • Phone: 706-494-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number13141
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003375
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: