Healthcare Provider Details

I. General information

NPI: 1992080436
Provider Name (Legal Business Name): ESOHE GRACE IDUSUYI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4944 SEPTEMBER CT NW
ACWORTH GA
30102-7915
US

IV. Provider business mailing address

4944 SEPTEMBER COURT
ACWORTH GA
30102
US

V. Phone/Fax

Practice location:
  • Phone: 770-975-9538
  • Fax:
Mailing address:
  • Phone: 770-975-9538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN144525NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: