Provider Demographics
NPI:1295189363
Name:TETTEY-ENYO, PHYLLIS A (NP-C)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:TETTEY-ENYO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:678-288-9555
Mailing Address - Fax:678-288-9556
Practice Address - Street 1:125 KING AVE STE 200
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6710
Practice Address - Country:US
Practice Address - Phone:706-369-4478
Practice Address - Fax:706-353-6639
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174444363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily