Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175L00000X | Homeopath | MT004039 | GA |
NPI | 1215307731 |
---|---|
Provider Name | Phyllicia Maddox |
First Address | Atlanta, GA 30308-1910 |
Second Address | Atlanta, GA 30308-1910 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2015 |
Last Update Date | 26/09/2015 |