Provider Demographics
NPI:1891675849
Name:DICKERSON-WHITFIELD, CONSUELA
Entity type:Individual
Prefix:
First Name:CONSUELA
Middle Name:
Last Name:DICKERSON-WHITFIELD
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 1:5385 FIVE FORKS TRICKUM RD STE N
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3018
Mailing Address - Country:US
Mailing Address - Phone:470-610-9299
Mailing Address - Fax:
Practice Address - Street 1:5385 FIVE FORKS TRICKUM RD STE N
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3018
Practice Address - Country:US
Practice Address - Phone:470-610-9299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2993387261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service