Provider Demographics
NPI:1255980926
Name:CONWELL, JAMIE MARIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:MARIE
Last Name:CONWELL
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 1:1770 DENNIS KEMP LN NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3938
Mailing Address - Country:US
Mailing Address - Phone:205-799-0778
Mailing Address - Fax:
Practice Address - Street 1:1770 DENNIS KEMP LN NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3938
Practice Address - Country:US
Practice Address - Phone:707-515-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN220281363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty