Healthcare Provider Details

I. General information

NPI: 1710919600
Provider Name (Legal Business Name): WON S JEON CNM, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WANDA JEON CNM

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5673 PEACHTREE DUNWOODY RD STE 870
ATLANTA GA
30342-5029
US

IV. Provider business mailing address

700 PIEDMONT AVE NE UNIT 3
ATLANTA GA
30308-4311
US

V. Phone/Fax

Practice location:
  • Phone: 404-255-2975
  • Fax: 404-255-2276
Mailing address:
  • Phone: 770-312-5228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN161911
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN161911
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: