Basic Information
| Provider Information | |||||||||
| NPI: | 1851659650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEPBURN | ||||||||
| FirstName: | MARIEL | ||||||||
| MiddleName: | DANITA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E STE 400 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 E WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317145315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295673407 | ||||||||
| FaxNumber: | 2295674467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2012 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 074668 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.