Provider Demographics
NPI:1083724637
Name:WILLEBY, JERI MELANIE (CNM)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:MELANIE
Last Name:WILLEBY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 FORSYTH ST
Mailing Address - Street 2:STE 3B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-743-3454
Mailing Address - Fax:478-743-6816
Practice Address - Street 1:1062 FORSYTH ST
Practice Address - Street 2:STE 3B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-743-3454
Practice Address - Fax:478-743-6816
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN047389367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA423BPJMedicare ID - Type Unspecified