Healthcare Provider Details

I. General information

NPI: 1275198400
Provider Name (Legal Business Name): JODENE MARIE NAGEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 LEBANON RD
LAWRENCEVILLE GA
30043-5116
US

IV. Provider business mailing address

1655 LEBANON RD STE A
LAWRENCEVILLE GA
30043-5116
US

V. Phone/Fax

Practice location:
  • Phone: 770-682-2024
  • Fax:
Mailing address:
  • Phone: 770-365-4784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberRN228794
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN228794
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: