Healthcare Provider Details

I. General information

NPI: 1831607142
Provider Name (Legal Business Name): BETSY ELEANE CUENCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

3217 SARAH LOU DR
SNELLVILLE GA
30078-5746
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-1000
  • Fax:
Mailing address:
  • Phone: 770-866-3810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number8906
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: