Healthcare Provider Details

I. General information

NPI: 1598111965
Provider Name (Legal Business Name): DIANA SOFIA VILLACIS NUNEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date: 12/30/2016
Reactivation Date: 04/27/2017

III. Provider practice location address

1400 TULLIE RD NE
ATLANTA GA
30329-2309
US

IV. Provider business mailing address

1400 TULLIE RD NE
ATLANTA GA
30329-2309
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax: 404-785-9096
Mailing address:
  • Phone: 404-785-5437
  • Fax: 404-785-9096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN23252
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82202
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number82202
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: