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General NPI Number Information
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NPI Number | 1992320089
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Entity Type | Organization
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Legal Business Name | ONE STICK MEDICAL ACADEMY
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Dates
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Enumeration Date | 06/15/2020
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Last Update Date | 06/15/2020
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Provider Practice Location Address
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Address Line | 101 BECKETT LN STE 505
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-7160
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Country | US
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Telephone | 912-661-9261
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Fax |
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Provider Business Mailing Address
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Address Line | 820 BETHSAIDA RD STE 101-46
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City | RIVERDALE
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State | GA
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Zip | 30274-2971
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Country | US
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Telephone | 912-661-9261
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEMISHA LATRICE JOHNSON
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Credential | PHLEBOTMIST, PARMED
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Telephone | 912-661-9261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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