Basic Information
Provider Information | |||||||||
NPI: | 1861709073 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WENSTROM | ||||||||
FirstName: | ELAINE | ||||||||
MiddleName: | TRIEU | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TRIEU | ||||||||
OtherFirstName: | ELAINE | ||||||||
OtherMiddleName: | ANH | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD, MPH | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 35 COLLIER RD NW | ||||||||
Address2: | SUITE 635 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303091613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043673014 | ||||||||
FaxNumber: | 4043673558 | ||||||||
Practice Location | |||||||||
Address1: | 35 COLLIER RD NW | ||||||||
Address2: | SUITE 635 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303091613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043673014 | ||||||||
FaxNumber: | 4043673558 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2010 | ||||||||
LastUpdateDate: | 10/31/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 074617 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 208M00000X | 074617 | GA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.