IVYDALE WELLNESS CENTER (NPI# 1659919066) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1659919066 |
| Entity Type | Organization |
| Organization Name | IVYDALE WELLNESS CENTER |
| Other Organization Name | IVYDALE WELLNESS CENTER |
| Practice Address |
361 Resource Pkwy Winder GA 30680-8364 |
| Mailing Address |
881 Ivydale Ln Lawrenceville GA 30045-7818 |
| Practice Telephone | 7702910419 |
| Mailing Telephone | 4048198701 |
| Mailing Fax Number | 2403488500 |
| Enumeration Date | 2019-12-16 |
| Last Update Date | 2020-10-27 |
| Authorized Official Name | ABLAVI ADODO AGOMESSOU (NURSE PRACTITIONER) |
| Authorized Official Telephone | 4048198701 |
| Authorized Official Credential | NP |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 208D00000X | General Practice | Allopathic & Osteopathic Physicians | ||
| N | 261QM1300X |
Clinic/Center Specialization: Multi-Specialty |
Ambulatory Health Care Facilities | ||
| N | 261QP2300X |
Clinic/Center Specialization: Primary Care |
Ambulatory Health Care Facilities | ||
| N | 363LF0000X |
Nurse Practitioner Specialization: Family |
Physician Assistants & Advanced Practice Nursing Providers | ||
| Y | 363LP0808X |
Nurse Practitioner Specialization: Psych/Mental Health |
Physician Assistants & Advanced Practice Nursing Providers |
| Other Name | Type Code |
|---|---|
| Ivydale Wellness Center | Doing Business As Name - Organization |
| Street Address |
361 RESOURCE PKWY |
| City | WINDER |
| State | GA |
| Zip Code | 30680-8364 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1326653783 | Ivydale Wellness Center LLC | Clinic/Center | 361 Resource Pkwy, Winder, GA 30680-8364 | 2020-09-12 |
| 1053925107 | Brendalyne Facia Tamba | Nurse Practitioner | 361 Resource Pkwy, Winder, GA 30680-8364 | 2020-09-06 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1326520776 | Alexandrea Hosch | Specialist/Technologist | 474 Lisa Circle, Winder, GA 30680 | 2018-09-02 |
| 1427574185 | Kristen Layfield Harbin | Dietitian, Registered | 827 Jefferson Hwy, Winder, GA 30680 | 2017-08-15 |
| 1417485715 | Staci Harwell Tebbetts | Optometrist | 279 N Broad St Ste C, Winder, GA 30680 | 2017-05-31 |
| 1609234947 | Carmichaels Home Medical Equipment Inc | Durable Medical Equipment & Medical Supplies | 289 N Broad St, Winder, GA 30680 | 2016-02-02 |
| 1699140434 | Chee Vang | Physical Therapy Assistant | 1012 Bowman Way, Winder, GA 30680 | 2015-12-04 |
| 1518361989 | Usrc Winder, LLC | Clinic/Center | 429 Loganville Hwy Ste 105-109, Winder, GA 30680 | 2014-10-14 |
| 1871901090 | Carol Lumpkin | Nurse Practitioner | 15 Porter St East, Winder, GA 30680 | 2014-07-31 |
| 1548501851 | Jennifer Won | Dentist | 444 Atlanta Hwy Nw Ste 500, Winder, GA 30680 | 2013-03-12 |
| 1801041595 | Joan Theresa James | Obstetrics & Gynecology | 137 W Athens St Ste 103, Winder, GA 30680 | 2008-11-21 |
| 1669636767 | Lee Lindsey Bleshoy | Nurse Practitioner | 133 W Athens St Ste A, Winder, GA 30680 | 2008-07-17 |
| Find all providers in zip 30680 | ||||
| Taxonomy Code | 363LP0808X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Psych/Mental Health |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1336740398 | Audline Maria Hodnett | Nurse Practitioner | 4805 W Village Way Se Apt 2208, Smyrna, GA 30080-9227 | 2020-11-05 |
| 1073111845 | George Mackel, Pmhnp-bc, LLC | Nurse Practitioner | 12034 Big Canoe, 400 Shetland Trace, Jasper, GA 30143 | 2020-10-14 |
| 1356958060 | Earl Delk | Nurse Practitioner | 3365 Ridgerock Way, Snellville, GA 30078-4176 | 2020-09-26 |
| 1609482991 | Tammy Haskins Bailey | Nurse Practitioner | 196 Laying Farm Rd Se, Milledgeville, GA 31061-9714 | 2020-09-22 |
| 1861007403 | Caring Clinic LLC | Nurse Practitioner | 114 Wrights Dr, Milledgeville, GA 31061 | 2020-09-10 |
| 1376156364 | Katrina Ransom Clark | Nurse Practitioner | 120 Walker Dr Nw, Milledgeville, GA 31061-9561 | 2020-08-28 |
| 1457963746 | Evelyn Ahiante Dennis | Nurse Practitioner | 3325 Emden Ct, Snellville, GA 30039-6047 | 2020-08-19 |
| 1194335620 | Jennifer Logan | Nurse Practitioner | 424 Scotts Way, Augusta, GA 30909-3135 | 2020-08-10 |
| 1750991592 | Jamie Rae Mccracken | Nurse Practitioner | 2538 Gordon Cir Se, Smyrna, GA 30080-8123 | 2020-08-06 |
| 1285244608 | Amcare Substance Abuse and Addiction Counseling | Nurse Practitioner | 3615 Hutchinson Rd Ste 203, Cumming, GA 30040-0501 | 2020-08-01 |
| Find all providers with the same taxonomy | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.