Provider Demographics
NPI:1871722827
Name:PETERS, WILLNELLA PATRAY (OD)
Entity type:Individual
Prefix:DR
First Name:WILLNELLA
Middle Name:PATRAY
Last Name:PETERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 BULLSBORO DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2190
Mailing Address - Country:US
Mailing Address - Phone:919-426-6466
Mailing Address - Fax:
Practice Address - Street 1:1108 BULLSBORO DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2190
Practice Address - Country:US
Practice Address - Phone:919-426-6466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist