IVYDALE WELLNESS CENTER NPI 1659919066

NPI Information

  • NPI: 1659919066
  • Provider Name: IVYDALE WELLNESS CENTER
  • Classification: Nurse Practitioner - 363LP0808X
  • Specialization: Psychiatric/Mental Health
  • Entity Type: Organization
  • Doing Business As: IVYDALE WELLNESS CENTER
  • CLIA Number: 11D2178274
  • Address: 361 RESOURCE PKWY
    WINDER, GA
    ZIP 30680
  • Phone: (770) 291-0419

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NPI Details

IVYDALE WELLNESS CENTER is a psychiatric/mental health nurse practitioner in Winder, GA. IVYDALE WELLNESS CENTER NPI is 1659919066. The provider is registered as an organization entity type and is a multi-specialty group.
The provider Is Doing Business As Ivydale Wellness Center.

The provider's business location address is:

361 RESOURCE PKWY
WINDER, GA
ZIP 30680-364
Phone: (770) 291-0419

The provider's authorized official is Ablavi Adodo Agomessou .
The authorized official title is Nurse Practitioner and has the following contact phone number (404) 819-8701.

The CLIA number assigned to this NPI record is 11D2178274 - practitioner other with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 12/16/2019 and was last updated on 10/27/2020.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1208D00000XGeneral PracticeNo
2261QM1300XClinic/CenterMulti-SpecialtyNo
3261QP2300XClinic/CenterPrimary CareNo
4363LF0000XNurse PractitionerFamilyNo
5363LP0808XNurse PractitionerPsychiatric/Mental HealthYes

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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