Healthcare Provider Details

I. General information

NPI: 1871986331
Provider Name (Legal Business Name): TIERRA SIMONE WELLS DNP, FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIERRA SIMONE JOHNSON FNP-C

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 COUNTRY CLUB DR
STOCKBRIDGE GA
30281-7349
US

IV. Provider business mailing address

275 COUNTRY CLUB DR
STOCKBRIDGE GA
30281-7349
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-8400
  • Fax: 770-474-3738
Mailing address:
  • Phone: 770-474-8400
  • Fax: 770-474-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN216891
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN216891
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: