Healthcare Provider Details

I. General information

NPI: 1356167803
Provider Name (Legal Business Name): ALLYSON BROOKE WAKENIGG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 QUILLIAN ST
CLEVELAND GA
30528-1464
US

IV. Provider business mailing address

273 QUILLIAN ST
CLEVELAND GA
30528-1464
US

V. Phone/Fax

Practice location:
  • Phone: 706-865-6800
  • Fax:
Mailing address:
  • Phone: 706-865-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: