Healthcare Provider Details

I. General information

NPI: 1851791446
Provider Name (Legal Business Name): ORLENA WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4865 BILL GARDNER PKWY
LOCUST GROVE GA
30248-3644
US

IV. Provider business mailing address

4865 BILL GARDNER PKWY
LOCUST GROVE GA
30248-3644
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-0100
  • Fax: 770-692-6190
Mailing address:
  • Phone: 770-692-0100
  • Fax: 770-692-6190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License NumberRN184183
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: