MEDICARE: KALIYAH JAHKEL BAILEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	12766	GA

General Provider Information

NPI Number	:	1194535757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALIYAH JAHKEL BAILEY PA-C

Provider Business Mailing Address
First Line	:	348 VISTA CREEK DR
Second Line	:
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-7782
Country	:	US
Telephone Number	:	917-531-7084
Fax Number	:

Provider Business Practice Location Address
First Line	:	2663 EASTERLY PL
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30035-4004
Country	:	US
Telephone Number	:	770-981-5511
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2025
Last Update Date	:	01/07/2025

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