Provider Demographics
NPI:1992769269
Name:WILSON-PHILLIPS, LYNETTE ROCHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:LYNETTE
Middle Name:ROCHELLE
Last Name:WILSON-PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5268 SANDY SHORES CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3957
Mailing Address - Country:US
Mailing Address - Phone:404-405-6863
Mailing Address - Fax:404-501-9744
Practice Address - Street 1:4112 E PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-1817
Practice Address - Country:US
Practice Address - Phone:404-296-7133
Practice Address - Fax:404-501-9744
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038132208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000681106CMedicaid
GA000681106BMedicaid