Healthcare Provider Details

I. General information

NPI: 1033938550
Provider Name (Legal Business Name): DAMEKA RUNISE WILSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 BYRD WAY
WARNER ROBINS GA
31088-8937
US

IV. Provider business mailing address

3550 OLD RIVER RD
FORTSON GA
31808-4254
US

V. Phone/Fax

Practice location:
  • Phone: 229-433-8526
  • Fax:
Mailing address:
  • Phone: 229-237-7627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number332253
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: