Healthcare Provider Details

I. General information

NPI: 1245149368
Provider Name (Legal Business Name): DIAMOND WILDER ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 RIVER PL
BRASELTON GA
30517-5600
US

IV. Provider business mailing address

2550 BLACKMON DR APT 125
DECATUR GA
30033-6158
US

V. Phone/Fax

Practice location:
  • Phone: 770-848-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN-NP295121
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: