Healthcare Provider Details

I. General information

NPI: 1497440093
Provider Name (Legal Business Name): EMILY DENNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR STE 450
LAWRENCEVILLE GA
30046-3370
US

IV. Provider business mailing address

631 PROFESSIONAL DR STE 450
LAWRENCEVILLE GA
30046-3370
US

V. Phone/Fax

Practice location:
  • Phone: 770-963-8030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number711400
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: