Provider Demographics
NPI:1215904446
Name:FORDHAM, DEANANNE D (PAC)
Entity type:Individual
Prefix:
First Name:DEANANNE
Middle Name:D
Last Name:FORDHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:DEANANNE
Other - Middle Name:
Other - Last Name:DEES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:RR 1 BOX 60
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31012-9501
Mailing Address - Country:US
Mailing Address - Phone:478-358-9436
Mailing Address - Fax:478-374-1478
Practice Address - Street 1:1223 PLAZA AVE
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6763
Practice Address - Country:US
Practice Address - Phone:478-374-3814
Practice Address - Fax:478-374-1478
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003393363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001203AMedicaid