Provider Demographics
NPI:1811402803
Name:BELAYNEH, WONGELAWIT TESFAYE (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:WONGELAWIT
Middle Name:TESFAYE
Last Name:BELAYNEH
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 NAPA VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:766 WALTHER RD STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8765
Practice Address - Country:US
Practice Address - Phone:770-736-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN212141363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care