Provider Demographics
NPI:1356300651
Name:HOLYFIELD, JA NA MONIQUE (PA)
Entity Type:Individual
Prefix:
First Name:JA NA
Middle Name:MONIQUE
Last Name:HOLYFIELD
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 1:211 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2721
Mailing Address - Country:US
Mailing Address - Phone:678-289-6747
Mailing Address - Fax:678-289-6750
Practice Address - Street 1:211 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2721
Practice Address - Country:US
Practice Address - Phone:678-289-6747
Practice Address - Fax:678-289-6750
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8078363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102387Medicaid