Healthcare Provider Details

I. General information

NPI: 1124827647
Provider Name (Legal Business Name): LACHIMA UWAOLUETAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 OLD CORDELE RD
ALBANY GA
31705-2456
US

IV. Provider business mailing address

205 OLD CORDELE RD
ALBANY GA
31705-2456
US

V. Phone/Fax

Practice location:
  • Phone: 470-457-2828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-2025-0025
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: