1306901467 NPI number — DR. TRACEY LYNN ST. JULIAN MD

Table of content: DR. TRACEY LYNN ST. JULIAN MD (NPI 1306901467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306901467 NPI number — DR. TRACEY LYNN ST. JULIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST. JULIAN
Provider First Name:
TRACEY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FISHER
Provider Other First Name:
TRACEY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306901467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 GLYNN STREET SOUTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-629-2702
Provider Business Mailing Address Fax Number:
770-176-9282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 GLYNN STREET SOUTH
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-629-2702
Provider Business Practice Location Address Fax Number:
770-909-5004
Provider Enumeration Date:
12/27/2006

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: 207V00000X , with the licence number:  054127 , 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: 547811054A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com