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General NPI Number Information
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NPI Number | 1497542773
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Entity Type | Individual
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Provider Name | MARK WILLIAM CVENGROS-EDENS APRN
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Gender | Male
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Dates
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Enumeration Date | 04/22/2025
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Last Update Date | 06/17/2025
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Provider Practice Location Address
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Address Line | 747 S 8TH ST STE C
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City | GRIFFIN
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State | GA
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Zip | 30224-4884
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Country | US
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Telephone | 770-228-1767
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Fax | 770-228-7562
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Provider Business Mailing Address
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Address Line | PO BOX 4439
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City | HOUSTON
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State | TX
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Zip | 77210-4439
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Country | US
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Telephone | 713-792-2991
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1193193
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN296180
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 296180
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License Number State | GA
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