Provider Demographics
NPI:1003235383
Name:WELLSTAR SURGICAL ASSOCIATES OF MARIETTA
Entity Type:Organization
Organization Name:WELLSTAR SURGICAL ASSOCIATES OF MARIETTA
Other - Org Name:WELLSTAR HOSPITAL KENNESTONE
Other - Org Type:Other Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:770-428-0462
Mailing Address - Street 1:195 APPLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-2625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER ST NE STE 130
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1156
Practice Address - Country:US
Practice Address - Phone:770-428-0462
Practice Address - Fax:770-428-0462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175391282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access