MEDICARE: MR. EJOVWOKE UGHWANOGHO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN164479	GA

General Provider Information

NPI Number	:	1669321477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EJOVWOKE UGHWANOGHO

Provider Business Mailing Address
First Line	:	680 OLD JOHNSON RD
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30045-6251
Country	:	US
Telephone Number	:	470-796-1471
Fax Number	:	470-796-1471

Provider Business Practice Location Address
First Line	:	680 OLD JOHNSON RD
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30045-6251
Country	:	US
Telephone Number	:	470-796-1471
Fax Number	:	470-796-1471

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2026
Last Update Date	:	05/21/2026

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