Provider Demographics
NPI:1124458476
Name:MOCK, EDNA SHARIE (CERT HAIR LOSS SPECI)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:SHARIE
Last Name:MOCK
Suffix:
Gender:F
Credentials:CERT HAIR LOSS SPECI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2956 VINE GROVE ST
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-1782
Mailing Address - Country:US
Mailing Address - Phone:770-990-3944
Mailing Address - Fax:770-439-8870
Practice Address - Street 1:2956 VINE GROVE ST
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-1782
Practice Address - Country:US
Practice Address - Phone:770-990-3944
Practice Address - Fax:770-439-8870
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-24
Last Update Date:2013-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1165031744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management