Healthcare Provider Details

I. General information

NPI: 1245278100
Provider Name (Legal Business Name): JOLEEN WIENER GORMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 03/13/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 GRAND AVENUE SW
FORT PAYNE AL
35967
US

IV. Provider business mailing address

907 GRAND AVENUE SW
FORT PAYNE AL
35967
US

V. Phone/Fax

Practice location:
  • Phone: 256-845-0428
  • Fax: 256-845-0469
Mailing address:
  • Phone: 256-845-0428
  • Fax: 256-845-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14962
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number00014962
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: