Provider Demographics
NPI:1912379421
Name:WISELEY, DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WISELEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:CHAUSSINAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:835 COGBURN AVENUE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1010
Mailing Address - Country:US
Mailing Address - Phone:770-422-8815
Mailing Address - Fax:770-422-8815
Practice Address - Street 1:1150 BROOKSTONE CENTRE PARKWAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4577
Practice Address - Country:US
Practice Address - Phone:706-257-4189
Practice Address - Fax:705-257-4194
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52195207N00000X, 363A00000X
GA7222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology