Provider Demographics
NPI:1457071425
Name:BALLARD, TONIKA M
Entity Type:Individual
Prefix:MRS
First Name:TONIKA
Middle Name:M
Last Name:BALLARD
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 1:4165 CLARKS TRL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8686
Mailing Address - Country:US
Mailing Address - Phone:404-484-5261
Mailing Address - Fax:
Practice Address - Street 1:4165 CLARKS TRL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8686
Practice Address - Country:US
Practice Address - Phone:404-484-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA04199017172A00000X
172A00000X
GA041990117172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver