Healthcare Provider Details

I. General information

NPI: 1629699947
Provider Name (Legal Business Name): REJEANA L DOBBS-GRANNUM RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8629 WOOD SPRINGS CT
DOUGLASVILLE GA
30135-1684
US

IV. Provider business mailing address

8629 WOOD SPRINGS CT
DOUGLASVILLE GA
30135-1684
US

V. Phone/Fax

Practice location:
  • Phone: 678-939-9099
  • Fax: 678-302-9601
Mailing address:
  • Phone: 678-939-9099
  • Fax: 678-302-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number246078
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: