1104446202 NPI number — MELANIE STREET HARPER

Table of content: MELANIE STREET HARPER (NPI 1104446202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104446202 NPI number — MELANIE STREET HARPER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARPER
Provider First Name:
MELANIE
Provider Middle Name:
STREET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104446202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 STERLING PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEACHTREE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30269-3600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-490-1048
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 STONEWALL AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-1547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-271-2107
Provider Business Practice Location Address Fax Number:
770-683-1991
Provider Enumeration Date:
04/20/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-20-46012 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003218736A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003243127B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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