Provider Demographics
NPI:1558060962
Name:JAMAL, SOFIA
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:JAMAL
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 1:2169 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7710
Mailing Address - Country:US
Mailing Address - Phone:770-676-5878
Mailing Address - Fax:
Practice Address - Street 1:2169 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7710
Practice Address - Country:US
Practice Address - Phone:770-676-5878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN262375363LW0102X, 163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RN262375OtherRN LICENSE