Healthcare Provider Details

I. General information

NPI: 1679226203
Provider Name (Legal Business Name): ANTIQUA WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 BUFORD HWY NE STE 700
ATLANTA GA
30324-5510
US

IV. Provider business mailing address

2751 BUFORD HWY NE STE 700
ATLANTA GA
30324-5510
US

V. Phone/Fax

Practice location:
  • Phone: 877-839-3988
  • Fax:
Mailing address:
  • Phone: 404-520-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number11D2240079
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: