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General NPI Number Information
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NPI Number | 1215904446
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Entity Type | Individual
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Provider Name | DEANANNE D FORDHAM PAC
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Gender | Female
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Dates
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Enumeration Date | 03/07/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 1223 PLAZA AVE
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City | EASTMAN
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State | GA
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Zip | 31023-6763
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Country | US
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Telephone | 478-374-3814
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Fax | 478-374-1478
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Provider Business Mailing Address
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Address Line | RR 1 BOX 60
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City | CHESTER
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State | GA
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Zip | 31012-9501
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Country | US
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Telephone | 478-358-9436
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Fax | 478-374-1478
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 003393
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License Number State | GA
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