Provider Demographics
NPI:1841675667
Name:WILBURN, KEMAYA
Entity type:Individual
Prefix:
First Name:KEMAYA
Middle Name:
Last Name:WILBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 HIDDEN CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-5572
Mailing Address - Country:US
Mailing Address - Phone:404-308-7475
Mailing Address - Fax:
Practice Address - Street 1:101 MARIETTA ST NW STE 350
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2724
Practice Address - Country:US
Practice Address - Phone:404-947-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213051363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily