Basic Information
| Provider Information | |||||||||
| NPI: | 1689625535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7527 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430170727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145336497 | ||||||||
| FaxNumber: | 6145668737 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303224200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047782700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39099 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 39099 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64094832 | 05 | KY | MEDICAID | 0463756 | 05 | OH | MEDICAID | 200835590 | 05 | IN | MEDICAID |