Healthcare Provider Details

I. General information

NPI: 1366925638
Provider Name (Legal Business Name): JESSICA LYNNE LIVATINO BREEDLOVE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTHSIDE FORSYTH DR
CUMMING GA
30041-7659
US

IV. Provider business mailing address

1200 NORTHSIDE FORSYTH DR
CUMMING GA
30041-7659
US

V. Phone/Fax

Practice location:
  • Phone: 770-844-3200
  • Fax: 770-844-3227
Mailing address:
  • Phone: 770-844-3200
  • Fax: 770-844-3227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN210521
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: