Basic Information
| Provider Information | |||||||||
| NPI: | 1174804702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ITACY | ||||||||
| FirstName: | RAYLLENSONS | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048811094 | ||||||||
| FaxNumber: | 4048741249 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 CUMMING HIGHWAY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785931295 | ||||||||
| FaxNumber: | 6785931294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2011 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 006147 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.