=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912123183
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE DELPHINE PARRIS P.A.-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 11/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2603 OSBORNE RD STE E
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558-8907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-627-2675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1372 PEMBRIDGE TRCE NW
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30152-5471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-627-2675
-----------------------------------------------------
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 | 004454
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------