Healthcare Provider Details

I. General information

NPI: 1982512208
Provider Name (Legal Business Name): EMMANUEL MADUABUCHIM JOHN APRN/ PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 MARKET PLACE BLVD # 136
CARTERSVILLE GA
30121-2235
US

IV. Provider business mailing address

269 MARKET PLACE BLVD # 136
CARTERSVILLE GA
30121-2235
US

V. Phone/Fax

Practice location:
  • Phone: 561-294-7619
  • Fax:
Mailing address:
  • Phone: 561-294-7619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP718972
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: