Ivydale Wellness Center LLC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

Legal business name

IVYDALE WELLNESS CENTER LLC

Doing business as

Ivydale Wellness Center

Practice address

361 Resource Pkwy
Winder, GA 30680-8364

Phone

(770) 291-0419

NPI assigned

Dec 16, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ablavi Adodo AgomessouNPI 1164885778

Title

Owner

Phone

(404) 819-8701

Specialties & licenses 2

Addresses

Other names 1

• Ivydale Wellness Center Doing business as

Medicare fee-for-service enrollment

Enrolled in GA, NY2 enrollments

Enrollment records 2

Tax ID family

Ivydale Wellness Center LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Ivydale Wellness Center LLC

  • Community/Behavioral Health Agency
  • Winder, GA
  • NPI 1326653783
  NPD tax ID

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Ablavi Agomessou, APRN

  • Psychiatric/Mental Health Nurse Practitioner
  • Lawrenceville, GA
  • NPI 1164885778

  Family, NY

  Medicare reassignment NPD Authorized official
• Taheerah D Freeman, FNP

  • Family Nurse Practitioner
  • Lawrenceville, GA
  • NPI 1306962436
  Medicare reassignment NPD
• Brendalyne Facia Tamba, FNP

  • Family Nurse Practitioner
  • Winder, GA
  • NPI 1053925107

  Single Specialty

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1576454400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1768435200000",
    "number": "1659919066",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "881 IVYDALE LN",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300457818",
            "telephone_number": "404-819-8701",
            "fax_number": "240-348-8500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "361 RESOURCE PKWY",
            "city": "WINDER",
            "state": "GA",
            "postal_code": "306808364",
            "telephone_number": "770-291-0419"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVYDALE WELLNESS CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-16",
        "last_updated": "2026-01-15",
        "certification_date": "2026-01-15",
        "status": "A",
        "authorized_official_last_name": "AGOMESSOU",
        "authorized_official_first_name": "ABLAVI",
        "authorized_official_middle_name": "ADODO",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "404-819-8701"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ivydale Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Ivydale Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Psychiatric/Mental Health Nurse Practitioner in Winder, GA
• Providers in Winder, GA by specialty
• Psychiatric/Mental Health Nurse Practitioner in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 15, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.