Provider Demographics
NPI:1912107160
Name:WARDY, DOUGLAS NOLAN (MA, ATC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:NOLAN
Last Name:WARDY
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 SATELLITE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4636
Mailing Address - Country:US
Mailing Address - Phone:770-865-8469
Mailing Address - Fax:
Practice Address - Street 1:1180 SATELLITE BLVD NW
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4636
Practice Address - Country:US
Practice Address - Phone:770-865-8469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0016802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer