MEDICARE: THERESA HANNAH WALCOT-CEESAY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN193249	GA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN193249	GA

General Provider Information

NPI Number	:	1093116410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA HANNAH WALCOT-CEESAY RN

Provider Business Mailing Address
First Line	:	5734 WINCHESTER PL
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-4082
Country	:	US
Telephone Number	:	404-859-3216
Fax Number	:

Provider Business Practice Location Address
First Line	:	5734 WINCHESTER PL
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-4082
Country	:	US
Telephone Number	:	404-859-3216
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2014
Last Update Date	:	11/25/2023

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