Healthcare Provider Details

I. General information

NPI: 1710638085
Provider Name (Legal Business Name): KAYLA WIGGINS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 01/18/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 CLAIREMONT AVE STE 200
DECATUR GA
30030-2546
US

IV. Provider business mailing address

160 CLAIREMONT AVE STE 200
DECATUR GA
30030-2546
US

V. Phone/Fax

Practice location:
  • Phone: 404-805-5575
  • Fax:
Mailing address:
  • Phone: 678-324-0264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN290903
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: