Provider Demographics
NPI:1568807741
Name:PRYOR, TEQUILLA L (MD)
Entity Type:Individual
Prefix:
First Name:TEQUILLA
Middle Name:L
Last Name:PRYOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TEQUILLA
Other - Middle Name:L
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:101 YORKTOWN DR STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1501
Mailing Address - Country:US
Mailing Address - Phone:770-460-4281
Mailing Address - Fax:770-460-4002
Practice Address - Street 1:101 YORKTOWN DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1501
Practice Address - Country:US
Practice Address - Phone:770-460-4281
Practice Address - Fax:770-460-4002
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101260570208000000X
390200000X
GA80923208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program