Individual
CHAELI WISENBAKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2412 N OAK ST, VALDOSTA, GA 31602-2567
(229) 244-1400
(229) 244-5512
Mailing address
3832 DANE LN, VALDOSTA, GA 31601
(229) 740-3604
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7207
GEORGIA LICENSE
GA
Enumeration date
06/03/2014
Last updated
05/20/2016
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