Provider Demographics
NPI:1497383038
Name:DORNBLASER, SHERYL
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:DORNBLASER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 MCKENDREE CHURCH RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5207
Mailing Address - Country:US
Mailing Address - Phone:770-962-0800
Mailing Address - Fax:
Practice Address - Street 1:1180 MCKENDREE CHURCH RD STE 107
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5207
Practice Address - Country:US
Practice Address - Phone:770-962-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAADC000273261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care