Healthcare Provider Details

I. General information

NPI: 1043508583
Provider Name (Legal Business Name): DANIEL KYLE WIESMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

IV. Provider business mailing address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1284
  • Fax:
Mailing address:
  • Phone: 404-778-1284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: