=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841964384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CECILIE MARIE STEGEMAN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2021
-----------------------------------------------------
Last Update Date | 08/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 371 E PACES FERRY RD NE STE 850
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-3293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-963-6665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1577 TIMBERRIDGE WAY
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-5280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-458-8321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 10483
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------