Provider Demographics
NPI:1578850459
Name:CASSAVETTES, WANDA LEE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LEE
Last Name:CASSAVETTES
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746071
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6071
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:126 PIN OAK PL
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:OH
Practice Address - Zip Code:44405-1683
Practice Address - Country:US
Practice Address - Phone:330-518-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP-026196363LA2100X
OHCOA-11658-NS364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health