Healthcare Provider Details

I. General information

NPI: 1528458270
Provider Name (Legal Business Name): NANCY MIYUMO OGENDO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD
AUSTELL GA
30106-1121
US

IV. Provider business mailing address

1635 OLD 41 HWY NW STE 112-328
KENNESAW GA
30152-4480
US

V. Phone/Fax

Practice location:
  • Phone: 770-674-8626
  • Fax: 770-732-5182
Mailing address:
  • Phone: 770-674-8626
  • Fax: 770-732-5182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN232091
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: