Healthcare Provider Details

I. General information

NPI: 1023468923
Provider Name (Legal Business Name): MATTIE TRAMMELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 E 12TH ST
WEST POINT GA
31833-1745
US

IV. Provider business mailing address

1008 E 12TH ST
WEST POINT GA
31833-1745
US

V. Phone/Fax

Practice location:
  • Phone: 706-645-5591
  • Fax:
Mailing address:
  • Phone: 706-645-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number263262940
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: