MEDICARE: MR. WILLIE C ONYILO RN

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	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	RN135600	GA

General Provider Information

NPI Number	:	1659668622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIE C ONYILO RN

Provider Business Mailing Address
First Line	:	3126 ESPLANADE CIR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-4221
Country	:	US
Telephone Number	:	404-349-5630
Fax Number	:

Provider Business Practice Location Address
First Line	:	3126 ESPLANADE CIR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-4221
Country	:	US
Telephone Number	:	404-349-5630
Fax Number	:

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

Provider Enumeration Date	:	06/29/2011
Last Update Date	:	06/29/2011

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