Provider Demographics
NPI:1578573820
Name:DOMVILLE, MARY M (PA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:DOMVILLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:MARY
Other - Last Name:PENNINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:524 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3805
Mailing Address - Country:US
Mailing Address - Phone:770-832-2775
Mailing Address - Fax:770-254-8680
Practice Address - Street 1:524 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3805
Practice Address - Country:US
Practice Address - Phone:770-832-2775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003494363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003494OtherSTATE LICENSE
GAG000000Medicare UPIN