Healthcare Provider Details

I. General information

NPI: 1588170641
Provider Name (Legal Business Name): WESDYDA DORIVAL GASSANT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 06/26/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 GREAT SHOALS CIRCLE
LAWRENCEVILLE GA
30045
US

IV. Provider business mailing address

1392 PRESERVE PARK DR
LOGANVILLE GA
30052-5828
US

V. Phone/Fax

Practice location:
  • Phone: 678-330-8054
  • Fax:
Mailing address:
  • Phone: 678-330-8054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number9583541
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number9583541
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number9583541
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN085393
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number9583541
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: