MEDICARE: LIFEGATE HEALTH & WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	261QH0100X	Health Service Clinic/Center
3	302R00000X	Health Maintenance Organization
4	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1508481862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEGATE HEALTH & WELLNESS

Provider Business Mailing Address
First Line	:	3784 HARRIS BLVD NW
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30144-6098
Country	:	US
Telephone Number	:	954-770-7059
Fax Number	:

Provider Business Practice Location Address
First Line	:	3784 HARRIS BLVD NW
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30144-6098
Country	:	US
Telephone Number	:	954-770-7059
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EMMANUELLE CHASSAGNE
Credential	:	ARNP
Telephone Number	:	954-770-7059

Provider Enumeration Date	:	06/12/2020
Last Update Date	:	06/12/2020

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Directions to “LIFEGATE HEALTH & WELLNESS ” Practice Location

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