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General NPI Number Information
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NPI Number | 1285134999
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Entity Type | Organization
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Legal Business Name | EVERGREEN PRIMARY CARE AND WELLNESS PC
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Dates
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Enumeration Date | 02/19/2018
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Last Update Date | 03/08/2018
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Provider Practice Location Address
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Address Line | 2450 ATLANTA HWY STE 803
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City | CUMMING
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State | GA
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Zip | 30040-1252
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Country | US
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Telephone | 470-253-7944
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Fax | 678-807-6144
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Provider Business Mailing Address
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Address Line | 5485 BETHELVIEW RD STE 360-331
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City | CUMMING
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State | GA
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Zip | 30040-9735
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Country | US
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Telephone | 470-253-7944
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Fax | 678-807-6144
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Authorized Official
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Title or Position | OWNER
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Name | MRS. HEATHER B WANNER
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Credential | NP-C
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Telephone | 470-253-7944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | RN229572
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN229572
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 52651
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License Number State | GA
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