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General NPI Number Information
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NPI Number | 1720514029
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Entity Type | Organization
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Legal Business Name | LAKESIDE FAMILY MEDICINE
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Dates
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Enumeration Date | 05/04/2017
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Last Update Date | 05/04/2017
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Provider Practice Location Address
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Address Line | 104 CARRINGTON PARK DR STE B
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City | GAINESVILLE
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State | GA
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Zip | 30504-6603
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Country | US
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Telephone | 770-899-3773
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Fax |
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Provider Business Mailing Address
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Address Line | 104 CARRINGTON PARK DR STE B
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City | GAINESVILLE
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State | GA
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Zip | 30504-6603
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Country | US
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Telephone | 770-899-3773
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Fax |
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | FOROOGH NARMANI-MOHAMMADI
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Credential | DNP, FNP-C
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Telephone | 770-899-3773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | F0514016
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License Number State | GA
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