Healthcare Provider Details

I. General information

NPI: 1326331042
Provider Name (Legal Business Name): DANIELLE IBELEMA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4062 PEACHTREE RD NE STE A-536
BROOKHAVEN GA
30319-3021
US

IV. Provider business mailing address

4062 PEACHTREE RD NE STE A-536
BROOKHAVEN GA
30319-3021
US

V. Phone/Fax

Practice location:
  • Phone: 678-322-8138
  • Fax:
Mailing address:
  • Phone: 678-827-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number76263
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number076263
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number76263
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number76263
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: