Provider Demographics
NPI:1467808246
Name:FIELDS, PHEDRA
Entity Type:Individual
Prefix:
First Name:PHEDRA
Middle Name:
Last Name:FIELDS
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 1:290 HIGHWAY 314
Mailing Address - Street 2:SUITE B
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7813
Mailing Address - Country:US
Mailing Address - Phone:404-994-7727
Mailing Address - Fax:
Practice Address - Street 1:290 HIGHWAY 314
Practice Address - Street 2:SUITE B
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7813
Practice Address - Country:US
Practice Address - Phone:404-994-7727
Practice Address - Fax:404-994-7728
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005981225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist