Healthcare Provider Details

I. General information

NPI: 1427561836
Provider Name (Legal Business Name): JEANETTE DORMIO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 LEBANON RD STE A
LAWRENCEVILLE GA
30043-5116
US

IV. Provider business mailing address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

V. Phone/Fax

Practice location:
  • Phone: 770-682-2024
  • Fax:
Mailing address:
  • Phone: 678-312-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN240821
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: