Healthcare Provider Details

I. General information

NPI: 1902433832
Provider Name (Legal Business Name): PEDIATRIC WELLNESS ASSOCIATES LLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 UPPER HEMBREE RD STE A
ROSWELL GA
30076-0914
US

IV. Provider business mailing address

1240 UPPER HEMBREE RD STE A
ROSWELL GA
30076-0914
US

V. Phone/Fax

Practice location:
  • Phone: 888-381-8556
  • Fax:
Mailing address:
  • Phone: 888-381-8556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MAIA ALEES WALTON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 888-381-8556