Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LF0000X | Nurse Practitioner - Family Medicine | R141244 | GA |
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | AP61163549 | WA |
NPI | 1013450816 |
---|---|
Provider Name | Ms. Dorothy Delisfort-Crisostomo |
First Address | Atlanta, GA 30305 |
Second Address | Jonesboro, GA 30236 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2016 |
Last Update Date | 23/12/2021 |