Healthcare Provider Details

I. General information

NPI: 1841611761
Provider Name (Legal Business Name): JEFFREY ANDREW FORBRICK NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 OLD NORCROSS RD SUITE 300
LAWRENCEVILLE GA
30046-3389
US

IV. Provider business mailing address

545 OLD NORCROSS RD SUITE 300
LAWRENCEVILLE GA
30046-3389
US

V. Phone/Fax

Practice location:
  • Phone: 678-541-0777
  • Fax:
Mailing address:
  • Phone: 678-541-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN212023
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN212023
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: