Basic Information
| Provider Information | |||||||||
| NPI: | 1750811691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARVEY | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | MCCANE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCANE | ||||||||
| OtherFirstName: | AMELIA | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 ASHLYN RDG | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302523947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783327026 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 150 N PARK TRL STE B | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302817372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705070909 | ||||||||
| FaxNumber: | 7705071919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8365 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | 8365 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | 8365 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.