Healthcare Provider Details

I. General information

NPI: 1225603897
Provider Name (Legal Business Name): PRINCESS AMAKA IKEMENOGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE
CONYERS GA
30012-3877
US

IV. Provider business mailing address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 470-788-1010
  • Fax:
Mailing address:
  • Phone: 206-543-2340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number113680
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number70006606
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: