Provider Demographics
NPI:1629082524
Name:ACKLIN, MARY VIRGINIA (CPNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:VIRGINIA
Last Name:ACKLIN
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Gender:F
Credentials:CPNP
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Mailing Address - Street 1:30 WARREN ST SE
Mailing Address - Street 2:DEKALB GRADY CLINIC
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30317-2267
Mailing Address - Country:US
Mailing Address - Phone:404-616-9304
Mailing Address - Fax:404-377-9324
Practice Address - Street 1:30 WARREN ST SE
Practice Address - Street 2:DEKALB GRADY CLINIC
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30317-2267
Practice Address - Country:US
Practice Address - Phone:404-616-9304
Practice Address - Fax:404-377-9324
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
GARN034948363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics