Provider Demographics
NPI:1942564844
Name:FORD, MARCELLA EDWARDS (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARCELLA
Middle Name:EDWARDS
Last Name:FORD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16011 KAIROS RD
Mailing Address - Street 2:STE 300
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5207
Mailing Address - Country:US
Mailing Address - Phone:804-330-4021
Mailing Address - Fax:
Practice Address - Street 1:396 HISTORIC HIGHWAY 441 N.
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-754-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN089263363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125831BMedicaid