Provider Demographics
NPI:1336836105
Name:GALLIMORE, STEPHANIE (CSFA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GALLIMORE
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 CEDARCREST RD STE 305-63
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8900
Mailing Address - Country:US
Mailing Address - Phone:762-500-3552
Mailing Address - Fax:
Practice Address - Street 1:2537 CEDARCREST RD STE 305-63
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8900
Practice Address - Country:US
Practice Address - Phone:762-500-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical