Provider Demographics
NPI:1871909150
Name:TOWNSEND, MARCELLA (CSA)
Entity type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:TOWNSEND
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 768873
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8211
Mailing Address - Country:US
Mailing Address - Phone:912-604-0905
Mailing Address - Fax:678-243-5735
Practice Address - Street 1:203 HARBOR LNDG
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:912-604-0905
Practice Address - Fax:678-243-5735
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4411363AS0400X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1518472299OtherPROSOURCE SURGICAL ASSISTING, LLC