Provider Demographics
NPI:1568617769
Name:STEWART, DORETHA
Entity Type:Individual
Prefix:
First Name:DORETHA
Middle Name:
Last Name:STEWART
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 1:4509 WINDSOR SPRING RD
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-5803
Mailing Address - Country:US
Mailing Address - Phone:706-288-6428
Mailing Address - Fax:706-592-3838
Practice Address - Street 1:4509 WINDSOR SPRING RD
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-5803
Practice Address - Country:US
Practice Address - Phone:706-288-6428
Practice Address - Fax:706-592-3838
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA37400000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide