Provider Demographics
NPI:1164104717
Name:ATTALLAH, DEMIANA (PA)
Entity Type:Individual
Prefix:
First Name:DEMIANA
Middle Name:
Last Name:ATTALLAH
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 1:1604 BILL ELLER DR
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-3146
Mailing Address - Country:US
Mailing Address - Phone:615-710-2834
Mailing Address - Fax:
Practice Address - Street 1:1193 FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-8880
Practice Address - Country:US
Practice Address - Phone:931-648-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant