=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174089452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOCILLI WALTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 831 AUBURN RD STE 230
-----------------------------------------------------
City | DACULA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30019-5437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-232-7332
-----------------------------------------------------
Fax | 470-300-1100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2716 WILDFLOWER WAY
-----------------------------------------------------
City | HOSCHTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30548-3653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-736-0460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | RN253106
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------