Healthcare Provider Details

I. General information

NPI: 1013000777
Provider Name (Legal Business Name): BARBARA MITCHELL WILSON CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 MCCLURE BRIDGE RD
DULUTH GA
30096-3131
US

IV. Provider business mailing address

PO BOX 1415
DULUTH GA
30096-0025
US

V. Phone/Fax

Practice location:
  • Phone: 770-476-7047
  • Fax: 770-476-5845
Mailing address:
  • Phone: 770-476-7047
  • Fax: 770-476-5845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR069686
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: