Healthcare Provider Details

I. General information

NPI: 1083098065
Provider Name (Legal Business Name): CERITA WILLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 THE EXCHANGE SE SUITE 330M
ATLANTA GA
30339-7400
US

IV. Provider business mailing address

1865 LYON AVE SW
ATLANTA GA
30331-8450
US

V. Phone/Fax

Practice location:
  • Phone: 404-216-2296
  • Fax:
Mailing address:
  • Phone: 404-216-2296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: