Provider Demographics
NPI:1538839816
Name:FAVIS, KEONA NICOLE (DC)
Entity type:Individual
Prefix:DR
First Name:KEONA
Middle Name:NICOLE
Last Name:FAVIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 HIGHWAY 138 SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4000
Mailing Address - Country:US
Mailing Address - Phone:318-800-1032
Mailing Address - Fax:
Practice Address - Street 1:1240 GA-54
Practice Address - Street 2:SUITE 503/504
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4332
Practice Address - Country:US
Practice Address - Phone:678-667-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor