Healthcare Provider Details

I. General information

NPI: 1891577185
Provider Name (Legal Business Name): MANDY WELLS CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 WHITE OAK DR SE
CARTERSVILLE GA
30121-2960
US

IV. Provider business mailing address

185 W MAIN ST
CENTRE AL
35960-1323
US

V. Phone/Fax

Practice location:
  • Phone: 267-776-5728
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number100269554
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: