Healthcare Provider Details

I. General information

NPI: 1396973665
Provider Name (Legal Business Name): MS. WANDA DENISE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 02/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3275 CREEKWAY LN
DECATUR GA
30034-4909
US

IV. Provider business mailing address

3275 CREEKWAY LN
DECATUR GA
30034-4909
US

V. Phone/Fax

Practice location:
  • Phone: 404-243-3865
  • Fax: 404-243-4368
Mailing address:
  • Phone: 404-243-3865
  • Fax: 888-320-1559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: