Provider Demographics
NPI:1467603761
Name:GIBBONS, WANDA L ROGLER (CNM)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L ROGLER
Last Name:GIBBONS
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 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-365-0966
Mailing Address - Fax:
Practice Address - Street 1:5780 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1554
Practice Address - Country:US
Practice Address - Phone:770-255-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN069862163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient