Provider Demographics
NPI:1881611663
Name:WHEELER-IKUESAN, LUELLA CORINE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:LUELLA
Middle Name:CORINE
Last Name:WHEELER-IKUESAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6633 EASTBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8945
Mailing Address - Country:US
Mailing Address - Phone:770-484-1802
Mailing Address - Fax:
Practice Address - Street 1:1990 LAKESIDE PKWY
Practice Address - Street 2:SUITE 170
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5884
Practice Address - Country:US
Practice Address - Phone:770-938-1757
Practice Address - Fax:770-938-1759
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN066854363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ67257Medicare UPIN
GA177581Medicare PIN