Healthcare Provider Details

I. General information

NPI: 1487192860
Provider Name (Legal Business Name): ERICA WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2890 MANGO CIR NW
ATLANTA GA
30318-3839
US

IV. Provider business mailing address

2890 MANGO CIR NW
ATLANTA GA
30318-3839
US

V. Phone/Fax

Practice location:
  • Phone: 470-809-3279
  • Fax:
Mailing address:
  • Phone: 470-809-3279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: