Healthcare Provider Details

I. General information

NPI: 1063975944
Provider Name (Legal Business Name): DONNAMARIE WILSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DONNA MARIE WILSON DONNA BUXTON

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 RIDGE AVE SW
ATLANTA GA
30315
US

IV. Provider business mailing address

1046 RIDGE AVE SW
ATLANTA GA
30315-1640
US

V. Phone/Fax

Practice location:
  • Phone: 404-688-1350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN146542
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License NumberRN146542
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: