Healthcare Provider Details

I. General information

NPI: 1548156706
Provider Name (Legal Business Name): MRS. OSARUMWENSE DESTINY UFUAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FAMILY MEDICINE CLINIC 800 GI MADDOX PARKWAY
CHATSWORTH GA
30705
US

IV. Provider business mailing address

1200 MEMORIAL DRIVE
DALTON GA
30720
US

V. Phone/Fax

Practice location:
  • Phone: 706-686-8015
  • Fax: 706-686-8221
Mailing address:
  • Phone: 706-226-8996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: