Provider Demographics
NPI:1043508583
Name:WIESMAN, DANIEL KYLE
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:KYLE
Last Name:WIESMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 N DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5307
Mailing Address - Country:US
Mailing Address - Phone:404-778-1284
Mailing Address - Fax:
Practice Address - Street 1:2165 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5307
Practice Address - Country:US
Practice Address - Phone:404-778-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS