1689198798 NPI number — DOMINIQUE JACQUELINE MCINTOSH FNP

Table of content: DOMINIQUE JACQUELINE MCINTOSH FNP (NPI 1689198798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689198798 NPI number — DOMINIQUE JACQUELINE MCINTOSH FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCINTOSH
Provider First Name:
DOMINIQUE
Provider Middle Name:
JACQUELINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCINTOSH
Provider Other First Name:
DOMINIQUE
Provider Other Middle Name:
JACQUELINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689198798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6829 DANFORTH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-6370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3720 HOLCOMB BRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEACHTREE CORNERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30092-4795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-263-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN195908 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)