Healthcare Provider Details

I. General information

NPI: 1104032218
Provider Name (Legal Business Name): LAURA RENAE WILSON MSN, APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA RENAE PHELPS MSN, APRN-BC

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 MEMORIAL DR STE D
STONE MOUNTAIN GA
30083-3236
US

IV. Provider business mailing address

5405 MEMORIAL DR STE D
STONE MOUNTAIN GA
30083-3236
US

V. Phone/Fax

Practice location:
  • Phone: 404-296-3800
  • Fax: 404-297-8753
Mailing address:
  • Phone: 404-296-3800
  • Fax: 404-297-8753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number004365
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number701633
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN247115
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: