Provider Demographics
NPI:1265500037
Name:WELLS, NANCY R
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:R
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BASSWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4514
Mailing Address - Country:US
Mailing Address - Phone:770-454-8126
Mailing Address - Fax:770-454-9987
Practice Address - Street 1:12 PERIMETER PARK DR
Practice Address - Street 2:SUITE # 102
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:770-454-8126
Practice Address - Fax:770-454-9987
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00254317AMedicaid
0126760001Medicare ID - Type Unspecified