Provider Demographics
NPI:1518904804
Name:GASTON, JEANETTE (NP)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:GASTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:
Other - Last Name:WIMBUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:95 COLLIER RD NW
Mailing Address - Street 2:STE 2035
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1796
Mailing Address - Country:US
Mailing Address - Phone:404-605-2800
Mailing Address - Fax:404-351-5983
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-605-2800
Practice Address - Fax:404-351-5983
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0639601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner