Provider Demographics
NPI:1720514029
Name:LAKESIDE FAMILY MEDICINE
Entity Type:Organization
Organization Name:LAKESIDE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:FOROOGH
Authorized Official - Middle Name:
Authorized Official - Last Name:NARMANI-MOHAMMADI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:770-899-3773
Mailing Address - Street 1:104 CARRINGTON PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-6603
Mailing Address - Country:US
Mailing Address - Phone:770-899-3773
Mailing Address - Fax:
Practice Address - Street 1:104 CARRINGTON PARK DR STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-6603
Practice Address - Country:US
Practice Address - Phone:770-899-3773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF0514016261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care