Healthcare Provider Details

I. General information

NPI: 1366266025
Provider Name (Legal Business Name): MRS. MAKAYLI RAE OWEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 N PATTERSON ST
VALDOSTA GA
31602-2512
US

IV. Provider business mailing address

5442 TROUPEVILLE RD
QUITMAN GA
31643-8248
US

V. Phone/Fax

Practice location:
  • Phone: 229-433-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF09260663
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: