Healthcare Provider Details

I. General information

NPI: 1669017273
Provider Name (Legal Business Name): ELMA OKOGBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4236 WEAVERS WHITE LN
AUSTELL GA
30106-8255
US

IV. Provider business mailing address

4236 WEAVERS WHITE LN
AUSTELL GA
30106-8255
US

V. Phone/Fax

Practice location:
  • Phone: 404-421-8238
  • Fax:
Mailing address:
  • Phone: 404-421-8238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN239488
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: