Provider Demographics
NPI:1184264525
Name:KOENIG, DEJA SHARI (NP)
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:SHARI
Last Name:KOENIG
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:DEJA
Other - Middle Name:SHARI
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4034 OAK HILL RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5026
Mailing Address - Country:US
Mailing Address - Phone:516-830-5338
Mailing Address - Fax:470-523-2573
Practice Address - Street 1:4400 BROWNSVILLE RD STE 105
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-8902
Practice Address - Country:US
Practice Address - Phone:516-830-5338
Practice Address - Fax:470-523-2573
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013548363LF0000X
GARN282683363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily