Healthcare Provider Details

I. General information

NPI: 1093116410
Provider Name (Legal Business Name): THERESA HANNAH WALCOT-CEESAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 11/25/2023
Certification Date: 11/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5734 WINCHESTER PL
LITHONIA GA
30038-4082
US

IV. Provider business mailing address

5734 WINCHESTER PL
LITHONIA GA
30038-4082
US

V. Phone/Fax

Practice location:
  • Phone: 404-859-3216
  • Fax:
Mailing address:
  • Phone: 404-859-3216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN193249
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN193249
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: