Provider Demographics
NPI:1861125155
Name:WELLS, TANDRENIKA
Entity type:Individual
Prefix:MS
First Name:TANDRENIKA
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 VILLAGE PARK DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5551
Mailing Address - Country:US
Mailing Address - Phone:860-894-9594
Mailing Address - Fax:
Practice Address - Street 1:3490 SOUTH COBB DRIVE SE.
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:770-433-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN197332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily