Provider Demographics
NPI:1215307731
Name:MADDOX, PHYLLICIA (MT)
Entity type:Individual
Prefix:
First Name:PHYLLICIA
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 PONCE DE LEON AVE NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1910
Mailing Address - Country:US
Mailing Address - Phone:678-600-1523
Mailing Address - Fax:
Practice Address - Street 1:214 PONCE DE LEON AVE NE
Practice Address - Street 2:SUITE 1
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1910
Practice Address - Country:US
Practice Address - Phone:404-987-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-26
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004039175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath