Healthcare Provider Details

I. General information

NPI: 1659919066
Provider Name (Legal Business Name): IVYDALE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 RESOURCE PKWY
WINDER GA
30680-8364
US

IV. Provider business mailing address

881 IVYDALE LN
LAWRENCEVILLE GA
30045-7818
US

V. Phone/Fax

Practice location:
  • Phone: 770-291-0419
  • Fax:
Mailing address:
  • Phone: 404-819-8701
  • Fax: 240-348-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ABLAVI ADODO AGOMESSOU
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 404-819-8701