Healthcare Provider Details

I. General information

NPI: 1528666518
Provider Name (Legal Business Name): SHMEIKA WILCOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3608 STONE RD SW
ATLANTA GA
30331-5306
US

IV. Provider business mailing address

3608 STONE RD SW
ATLANTA GA
30331-5306
US

V. Phone/Fax

Practice location:
  • Phone: 678-768-0621
  • Fax:
Mailing address:
  • Phone: 678-768-0621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberCN0000104698
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number621209090009
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: