Provider Demographics
NPI:1447565668
Name:WILEY, KERRI L (NP-C)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:L
Last Name:WILEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12192 AUGUSTA ROAD
Mailing Address - Street 2:
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-1209
Mailing Address - Country:US
Mailing Address - Phone:706-356-1072
Mailing Address - Fax:706-356-1457
Practice Address - Street 1:12192 AUGUSTA ROAD
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1209
Practice Address - Country:US
Practice Address - Phone:706-356-1072
Practice Address - Fax:706-356-1457
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA192545363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA669649351AMedicaid
GA202I502274Medicare PIN