Individual
MRS. MARY M DOMVILLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
524 DIXIE ST, CARROLLTON, GA 30117-3805
(770) 832-2775
Mailing address
524 DIXIE ST, CARROLLTON, GA 30117-3805
(770) 832-2775
(770) 254-8680
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
003494
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003494
STATE LICENSE
GA
Enumeration date
08/09/2006
Last updated
02/13/2009
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