Healthcare Provider Details

I. General information

NPI: 1427329994
Provider Name (Legal Business Name): KATHERINE GRACE WUNDERLE CNM, ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2012
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 JOHNSON FY RD NE ST 800
ATLANTA GA
30342-1709
US

IV. Provider business mailing address

1100 JOHNSON FY RD NE ST 800
ATLANTA GA
30342-1709
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-1137
  • Fax:
Mailing address:
  • Phone: 404-252-1137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN247235
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: