Provider Demographics
NPI:1346010899
Name:WORTHAM, FALLON
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:WORTHAM
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 1:9 PINE GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-2897
Mailing Address - Country:US
Mailing Address - Phone:678-516-1160
Mailing Address - Fax:
Practice Address - Street 1:110 BRAXTON CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1968
Practice Address - Country:US
Practice Address - Phone:770-461-6422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA191643363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health