Provider Demographics
NPI:1740692813
Name:VANWONTERGHEM, OLENA
Entity type:Individual
Prefix:
First Name:OLENA
Middle Name:
Last Name:VANWONTERGHEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 CALGARY DR
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2747
Mailing Address - Country:US
Mailing Address - Phone:586-350-6839
Mailing Address - Fax:
Practice Address - Street 1:15 BAYNARD PARK
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6413
Practice Address - Country:US
Practice Address - Phone:770-251-5253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA77323208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program