Basic Information
| Provider Information | |||||||||
| NPI: | 1558493619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRICE | ||||||||
| FirstName: | LETITIA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704953396 | ||||||||
| FaxNumber: | 7704952307 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 OLD NORTON RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302154872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788171117 | ||||||||
| FaxNumber: | 6788170823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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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 | 363AM0700X | 005009 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | CA9328 | 01 | GA | MEDICARE GROUP-DMERC | OTHER | 747792658A | 05 | GA | MEDICAID |