=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801520564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYN HAYWARD DEYOUNG PA-C, MPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2022
-----------------------------------------------------
Last Update Date | 04/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5582 MEMORIAL DR
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 44-927-3464
-----------------------------------------------------
Fax | 404-297-7595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5582 MEMORIAL DR
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-492-7346
-----------------------------------------------------
Fax | 404-297-7595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 11451
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------