Provider Demographics
NPI:1275269516
Name:GORDWIN, JALESHA CHAYELLE (FNP)
Entity Type:Individual
Prefix:
First Name:JALESHA
Middle Name:CHAYELLE
Last Name:GORDWIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3723 JOLANE TER SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3874
Mailing Address - Country:US
Mailing Address - Phone:601-434-3576
Mailing Address - Fax:
Practice Address - Street 1:980 JOHNSON FERRY RD STE 900
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4768
Practice Address - Country:US
Practice Address - Phone:404-459-1900
Practice Address - Fax:404-459-1903
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN245605363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner