1528108099 NPI number — DR. CORNELIA WENZE ED.D.

Table of content: DR. CORNELIA WENZE ED.D. (NPI 1528108099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528108099 NPI number — DR. CORNELIA WENZE ED.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENZE
Provider First Name:
CORNELIA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528108099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 MAIN ST UNIT 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTERDALE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30070-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-618-4843
Provider Business Mailing Address Fax Number:
470-441-9183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 LANIER AVE W STE 103B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-7640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-800-4002
Provider Business Practice Location Address Fax Number:
404-393-5698
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  010382 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: MH7527 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 015228700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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