Provider Demographics
NPI:1659919066
Name:IVYDALE WELLNESS CENTER
Entity Type:Organization
Organization Name:IVYDALE WELLNESS CENTER
Other - Org Name:IVYDALE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ABLAVI
Authorized Official - Middle Name:ADODO
Authorized Official - Last Name:AGOMESSOU
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-819-8701
Mailing Address - Street 1:881 IVYDALE LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7818
Mailing Address - Country:US
Mailing Address - Phone:404-819-8701
Mailing Address - Fax:240-348-8500
Practice Address - Street 1:361 RESOURCE PKWY
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8364
Practice Address - Country:US
Practice Address - Phone:770-291-0419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty