Healthcare Provider Details

I. General information

NPI: 1912379421
Provider Name (Legal Business Name): DANIELLE WISELEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE CHAUSSINAND PA-C

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 BROOKSTONE CENTRE PARKWAY
COLUMBUS GA
31904-4577
US

IV. Provider business mailing address

835 COGBURN AVENUE SUITE 250
MARIETTA GA
30060-1010
US

V. Phone/Fax

Practice location:
  • Phone: 706-257-4189
  • Fax: 705-257-4194
Mailing address:
  • Phone: 770-422-8815
  • Fax: 770-422-8815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA52195
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA52195
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7222
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: