Provider Demographics
NPI:1659016822
Name:OVERTON, VALEDA ANN
Entity Type:Individual
Prefix:
First Name:VALEDA
Middle Name:ANN
Last Name:OVERTON
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 1:7317 WAGON WHEEL CT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2547
Mailing Address - Country:US
Mailing Address - Phone:678-698-0200
Mailing Address - Fax:
Practice Address - Street 1:7317 WAGON WHEEL CT
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2547
Practice Address - Country:US
Practice Address - Phone:678-698-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052709073172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty