Healthcare Provider Details

I. General information

NPI: 1497518484
Provider Name (Legal Business Name): IWALANI REISER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UPPER RIVERDALE ROAD
RIVERDALE GA
30274
US

IV. Provider business mailing address

2945 CUMBERLAND MALL SE APT 3030
ATLANTA GA
30339-5189
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-8000
  • Fax:
Mailing address:
  • Phone: 678-362-8085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number279764
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: