MEDICARE: MRS. MICHELE LEE WIEGMANN-ROSS CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	RN145899NP	GA

General Provider Information

NPI Number	:	1619169968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELE LEE WIEGMANN-ROSS CPNP

Provider Business Mailing Address
First Line	:	1115 MOUNT ZION RD
Second Line	:	SUITE E
City	:	MORROW
State	:	GA
Zip	:	30260-2266
Country	:	US
Telephone Number	:	770-960-9999
Fax Number	:	770-960-0931

Provider Business Practice Location Address
First Line	:	1115 MOUNT ZION RD
Second Line	:	SUITE E
City	:	MORROW
State	:	GA
Zip	:	30260-2266
Country	:	US
Telephone Number	:	770-960-9999
Fax Number	:	770-960-0931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2007
Last Update Date	:	07/13/2015

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