Provider Demographics
NPI:1962453498
Name:HAWKINS, STEPHANIE KEAL (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KEAL
Last Name:HAWKINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 BOULDERCREST DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2268
Mailing Address - Country:US
Mailing Address - Phone:404-291-3711
Mailing Address - Fax:404-778-4472
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:SUITE B6168
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-3094
Practice Address - Fax:404-778-4472
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA363816690BMedicaid
GA363816690AMedicaid
GA363816690AMedicaid
GA363816690BMedicaid