MEDICARE: PEACE DZIGBORDI DORMON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5010507	NC

General Provider Information

NPI Number	:	1952890824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PEACE DZIGBORDI DORMON

Provider Business Mailing Address
First Line	:	5695 NEW AVEDON DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27455-8399
Country	:	US
Telephone Number	:	336-790-2850
Fax Number	:

Provider Business Practice Location Address
First Line	:	5695 NEW AVEDON DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27455-8399
Country	:	US
Telephone Number	:	336-790-2850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2018
Last Update Date	:	05/07/2018

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