Organization
GRADY HEALTH SYSTEM
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LATOYA BOOTH WISE CRNA (ANESTHETIST)
(404) 379-7052
Entity
Organization
Contact information
Practice address
180 VICTORIA DR, FAYETTEVILLE, GA 30214-1163
(404) 379-7052
Mailing address
180 VICTORIA DR, FAYETTEVILLE, GA 30214-1163
(404) 379-7052
Taxonomy
Speciality
Code
Description
License number
State
282NC0060X
Critical Access Hospital
Primary
161834
GA
Other
Enumeration date
12/26/2010
Last updated
12/26/2010
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