Provider Demographics
NPI:1063009470
Name:DASTINE-CORIOLAN, JOHANNE (NP)
Entity Type:Individual
Prefix:
First Name:JOHANNE
Middle Name:
Last Name:DASTINE-CORIOLAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 GROVE LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8155
Mailing Address - Country:US
Mailing Address - Phone:770-696-1350
Mailing Address - Fax:
Practice Address - Street 1:4344 GROVE LAKE ST
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8155
Practice Address - Country:US
Practice Address - Phone:770-696-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208229363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology