IVYDALE WELLNESS CENTER NPI 1659919066

NPI Information

NPI: 1659919066
Provider Name: IVYDALE WELLNESS CENTER

Doing Business As: IVYDALE WELLNESS CENTER

Classification: Nurse Practitioner - 363LP0808X
Entity Type: Organization

Specialization: Psychiatric/Mental Health

Address:
361 RESOURCE PKWY
WINDER, GA
ZIP 30680
Phone: (770) 291-0419
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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	Primary
1	208D00000X	General Practice		No
2	261QM1300X	Clinic/Center	Multi-Specialty	No
3	261QP2300X	Clinic/Center	Primary Care	No
4	363LF0000X	Nurse Practitioner	Family	No
5	363LP0808X	Nurse Practitioner	Psychiatric/Mental Health	Yes

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: 5/5/2024

NPI Synchronization or Removal

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