Healthcare Provider Details

I. General information

NPI: 1336241371
Provider Name (Legal Business Name): P LYNN WISEMAN CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA NEWTON

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CRESCENT CENTRE PARK DEPARTMENT OF BEHAVIORAL HEALTH
TUCKER GA
30084
US

IV. Provider business mailing address

3495 PIEDMONT ROAD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1736
US

V. Phone/Fax

Practice location:
  • Phone: 770-496-3609
  • Fax: 770-496-3708
Mailing address:
  • Phone: 404-364-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberRN126821
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: