Healthcare Provider Details

I. General information

NPI: 1497542773
Provider Name (Legal Business Name): MARK WILLIAM CVENGROS-EDENS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 S 8TH ST STE C
GRIFFIN GA
30224-4884
US

IV. Provider business mailing address

PO BOX 4439
HOUSTON TX
77210-4439
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-1767
  • Fax: 770-228-7562
Mailing address:
  • Phone: 713-792-2991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1193193
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN296180
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number296180
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: