Healthcare Provider Details

I. General information

NPI: 1013561323
Provider Name (Legal Business Name): ASSUMPTA OGBEDEAGU MS-FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 HIGHWAY 138 NE
CONYERS GA
30013-1110
US

IV. Provider business mailing address

PO BOX 51
JERSEY GA
30018-0051
US

V. Phone/Fax

Practice location:
  • Phone: 303-214-8017
  • Fax:
Mailing address:
  • Phone: 303-214-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN232512
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: