Provider Demographics
NPI:1689198798
Name:MCINTOSH, DOMINIQUE JACQUELINE (FNP)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JACQUELINE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:JACQUELINE
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6829 DANFORTH WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3720 HOLCOMB BRIDGE RD
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-4795
Practice Address - Country:US
Practice Address - Phone:770-263-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily