Healthcare Provider Details

I. General information

NPI: 1659084366
Provider Name (Legal Business Name): JACQUELENE LYNNETTE VARGAS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 S PARK ST
CARROLLTON GA
30117-3826
US

IV. Provider business mailing address

641 NORTH AVE NE APT 3119
ATLANTA GA
30308-3068
US

V. Phone/Fax

Practice location:
  • Phone: 404-948-3019
  • Fax:
Mailing address:
  • Phone: 708-207-1531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN276379
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN276379
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: