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General NPI Number Information
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NPI Number | 1659602126
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Entity Type | Organization
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Legal Business Name | WELL WOMAN LLC
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Dates
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Enumeration Date | 01/23/2010
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Last Update Date | 01/23/2010
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Provider Practice Location Address
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Address Line | 769 KNOX SPRINGS RD
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City | AUSTELL
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State | GA
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Zip | 30168-6313
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Country | US
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Telephone | 678-463-0253
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Fax |
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Provider Business Mailing Address
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Address Line | 769 KNOX SPRINGS RD
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City | AUSTELL
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State | GA
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Zip | 30168-6313
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MARKEITA MCINTOSH
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Credential | PA
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Telephone | 678-463-0253
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 03495
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License Number State | GA
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