Provider Demographics
NPI:1285054742
Name:HOUSTON, PEAESHA LYNETTE (DO)
Entity type:Individual
Prefix:DR
First Name:PEAESHA
Middle Name:LYNETTE
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:4445 S LEE ST STE 105
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-8806
Practice Address - Country:US
Practice Address - Phone:770-848-9240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6754390200000X
GA78196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program