Healthcare Provider Details

I. General information

NPI: 1548444573
Provider Name (Legal Business Name): JENNIFER CARTER WIEGAND ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5281 CLEVELAND HWY
CLERMONT GA
30527-2205
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-983-4611
  • Fax: 770-983-9143
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN126531
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN126531
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: