Provider Demographics
NPI:1285134999
Name:EVERGREEN PRIMARY CARE AND WELLNESS PC
Entity type:Organization
Organization Name:EVERGREEN PRIMARY CARE AND WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:B
Authorized Official - Last Name:WANNER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:470-253-7944
Mailing Address - Street 1:5485 BETHELVIEW RD STE 360-331
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-9735
Mailing Address - Country:US
Mailing Address - Phone:470-253-7944
Mailing Address - Fax:678-807-6144
Practice Address - Street 1:2450 ATLANTA HWY STE 803
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1252
Practice Address - Country:US
Practice Address - Phone:470-253-7944
Practice Address - Fax:678-807-6144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-19
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN229572207QG0300X, 363LF0000X
GA52651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty