Provider Demographics
NPI:1013450816
Name:DELISFORT-CRISOSTOMO, DOROTHY (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:
Last Name:DELISFORT-CRISOSTOMO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:
Other - Last Name:DELISFORT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4228 1ST AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4426
Mailing Address - Country:US
Mailing Address - Phone:833-583-4778
Mailing Address - Fax:833-583-4779
Practice Address - Street 1:4228 1ST AVE STE 1
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4426
Practice Address - Country:US
Practice Address - Phone:833-583-4778
Practice Address - Fax:833-583-4779
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN141244363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily