Provider Demographics
NPI:1962892745
Name:MCKINNIES-WESLEY, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:MCKINNIES-WESLEY
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 1:3375 CENTERVILLE HWY UNIT 392624
Mailing Address - Street 2:#392624
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-0125
Mailing Address - Country:US
Mailing Address - Phone:404-797-8776
Mailing Address - Fax:404-601-4267
Practice Address - Street 1:4200 RIVERLAKE WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-8722
Practice Address - Country:US
Practice Address - Phone:678-344-8849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver