Provider Demographics
NPI:1326480666
Name:CONYERS WALKI IN CLINIC
Entity Type:Organization
Organization Name:CONYERS WALKI IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:770-679-9935
Mailing Address - Street 1:1810 HIGHWAY 20 SE
Mailing Address - Street 2:SUITE172
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2001
Mailing Address - Country:US
Mailing Address - Phone:770-679-9935
Mailing Address - Fax:770-679-9938
Practice Address - Street 1:1810 HIGHWAY 20 SE
Practice Address - Street 2:SUITE172
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2001
Practice Address - Country:US
Practice Address - Phone:770-679-9935
Practice Address - Fax:770-679-9938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA206177261QU0200X
GARN206177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1306986427Medicaid