Healthcare Provider Details

I. General information

NPI: 1073967055
Provider Name (Legal Business Name): PRISTELLA OHANAJA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 N 5TH STREET EXT
CORDELE GA
31015-3776
US

IV. Provider business mailing address

PO BOX 4881
MACON GA
31208-4881
US

V. Phone/Fax

Practice location:
  • Phone: 229-273-4100
  • Fax: 229-273-0092
Mailing address:
  • Phone: 229-273-4100
  • Fax: 229-273-0092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN170626
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN170626
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: