Provider Demographics
NPI:1912406307
Name:DATTA, POONAM
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:DATTA
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 1:510 BUTLER NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5944
Mailing Address - Country:US
Mailing Address - Phone:770-317-4533
Mailing Address - Fax:844-461-5939
Practice Address - Street 1:5675 JIMMY CARTER BLVD STE 665A
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2955
Practice Address - Country:US
Practice Address - Phone:770-317-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker