Healthcare Provider Details

I. General information

NPI: 1316378979
Provider Name (Legal Business Name): MELANIE WARDLE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SUN VALLEY DR SUITE D
ROSWELL GA
30076-5612
US

IV. Provider business mailing address

555 SUN VALLEY DR SUITE D
ROSWELL GA
30076-5612
US

V. Phone/Fax

Practice location:
  • Phone: 678-990-5401
  • Fax:
Mailing address:
  • Phone: 678-990-5401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN244086
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP9278847
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: