Provider Demographics
NPI:1891981130
Name:REGIS, MICALINE
Entity Type:Individual
Prefix:
First Name:MICALINE
Middle Name:
Last Name:REGIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICALINE
Other - Middle Name:
Other - Last Name:PENNIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:95 COLLIER RD NW
Mailing Address - Street 2:SUITE 2035
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1796
Mailing Address - Country:US
Mailing Address - Phone:404-605-2800
Mailing Address - Fax:404-351-5983
Practice Address - Street 1:95 COLLIER RD NW
Practice Address - Street 2:SUITE 2035
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1796
Practice Address - Country:US
Practice Address - Phone:404-605-2800
Practice Address - Fax:404-351-5983
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005194363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA652218080BMedicaid
GA652218080BMedicaid