Provider Demographics
NPI:1588170641
Name:GASSANT, WESDYDA DORIVAL (RN)
Entity type:Individual
Prefix:MRS
First Name:WESDYDA
Middle Name:DORIVAL
Last Name:GASSANT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 PRESERVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5828
Mailing Address - Country:US
Mailing Address - Phone:678-330-8054
Mailing Address - Fax:
Practice Address - Street 1:1623 GREAT SHOALS CIRCLE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045
Practice Address - Country:US
Practice Address - Phone:678-330-8054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9583541163WA0400X, 163WP0200X, 163WP0809X, 261QM0801X
GALPN085393164W00000X
GALPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty
No163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Multi-Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)