Provider Demographics
NPI:1851476188
Name:GIELISSE, INGRID MARIA (DC)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:MARIA
Last Name:GIELISSE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2733
Mailing Address - Country:US
Mailing Address - Phone:770-509-9717
Mailing Address - Fax:770-509-8796
Practice Address - Street 1:1307 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 4000
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2733
Practice Address - Country:US
Practice Address - Phone:770-509-9717
Practice Address - Fax:770-509-8796
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCFKMMedicare ID - Type Unspecified
GAU73006Medicare UPIN