=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396624979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARMALADE PALLATIVE HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2025
-----------------------------------------------------
Last Update Date | 09/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 AZALEA CT
-----------------------------------------------------
City | SOCIAL CIRCLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30025-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-464-5858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 AZALEA CT
-----------------------------------------------------
City | SOCIAL CIRCLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30025-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-464-5858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. ELLEN T PETRY
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 770-464-5858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------