Provider Demographics
NPI:1629699947
Name:DOBBS-GRANNUM, REJEANA L (RPT)
Entity Type:Individual
Prefix:MRS
First Name:REJEANA
Middle Name:L
Last Name:DOBBS-GRANNUM
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8629 WOOD SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1684
Mailing Address - Country:US
Mailing Address - Phone:678-939-9099
Mailing Address - Fax:678-302-9601
Practice Address - Street 1:8629 WOOD SPRINGS CT
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1684
Practice Address - Country:US
Practice Address - Phone:678-939-9099
Practice Address - Fax:678-302-9601
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246078202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL246078OtherAMT CERTIFICATION