Provider Demographics
NPI:1497095665
Name:DOLLISON, GENNIENE LYNETT
Entity Type:Individual
Prefix:MRS
First Name:GENNIENE
Middle Name:LYNETT
Last Name:DOLLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:GENNIENE
Other - Middle Name:LYNETT
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7071 STEPHENS CT
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-3236
Mailing Address - Country:US
Mailing Address - Phone:404-901-4108
Mailing Address - Fax:
Practice Address - Street 1:7071 STEPHENS CT
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-3236
Practice Address - Country:US
Practice Address - Phone:404-901-4108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA771094OtherDEFENSIVE DRIVER CERTIFICATION