Healthcare Provider Details

I. General information

NPI: 1427644640
Provider Name (Legal Business Name): JENNIFER MICHELLE BASTECKI FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2020
Last Update Date: 12/13/2020
Certification Date: 12/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11459 JOHNS CREEK PKWY STE 250
DULUTH GA
30097-3517
US

IV. Provider business mailing address

350 LA PERLA DR
SUGAR HILL GA
30518-6161
US

V. Phone/Fax

Practice location:
  • Phone: 770-497-1555
  • Fax:
Mailing address:
  • Phone: 770-366-8853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN223372
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: