Provider Demographics
NPI:1114168143
Name:WANYO, GAIL (DC)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:WANYO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 CANTON RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2660
Mailing Address - Country:US
Mailing Address - Phone:678-445-2166
Mailing Address - Fax:
Practice Address - Street 1:3660 CANTON RD STE 110
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-2660
Practice Address - Country:US
Practice Address - Phone:678-445-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-22
Last Update Date:2009-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA03140111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor