Provider Demographics
NPI:1972250025
Name:MADDIX, BRIANA MARIE
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:MARIE
Last Name:MADDIX
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 1:822 KAITLYN DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6929
Mailing Address - Country:US
Mailing Address - Phone:347-649-4940
Mailing Address - Fax:
Practice Address - Street 1:822 KAITLYN DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6929
Practice Address - Country:US
Practice Address - Phone:347-649-4940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057021701171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA057021701OtherDRIVERS LICENSE