Provider Demographics
NPI:1952594236
Name:SWAIN, KACIE J (PA)
Entity Type:Individual
Prefix:MRS
First Name:KACIE
Middle Name:J
Last Name:SWAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KACIE
Other - Middle Name:L
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:801 W GORDON ST
Practice Address - Street 2:ER DEPT
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3426
Practice Address - Country:US
Practice Address - Phone:706-647-5981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant