Provider Demographics
NPI:1992914220
Name:SELLERS, TWILA R
Entity type:Individual
Prefix:
First Name:TWILA
Middle Name:R
Last Name:SELLERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S MAIN ST
Mailing Address - Street 2:STE 5
Mailing Address - City:HIAWASSEE
Mailing Address - State:GA
Mailing Address - Zip Code:30546
Mailing Address - Country:US
Mailing Address - Phone:706-896-2872
Mailing Address - Fax:706-896-2873
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:STE 5
Practice Address - City:HIAWASSEE
Practice Address - State:GA
Practice Address - Zip Code:30546-3249
Practice Address - Country:US
Practice Address - Phone:706-896-2872
Practice Address - Fax:706-896-2873
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703186Medicaid
NC7703186Medicaid