Provider Demographics
NPI:1720703945
Name:MOUSSIGNAC-DEVILME, CORIE (PAC)
Entity Type:Individual
Prefix:
First Name:CORIE
Middle Name:
Last Name:MOUSSIGNAC-DEVILME
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PHILIP BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8746
Mailing Address - Country:US
Mailing Address - Phone:770-822-5560
Mailing Address - Fax:770-822-4989
Practice Address - Street 1:301 PHILIP BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8746
Practice Address - Country:US
Practice Address - Phone:770-822-5560
Practice Address - Fax:770-822-4989
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant