Healthcare Provider Details

I. General information

NPI: 1134703705
Provider Name (Legal Business Name): KODJO VIVIEN AZIAMADJI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 12/16/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6238 TURNER LAKE RD SW
COVINGTON GA
30014-3057
US

IV. Provider business mailing address

1477 ROGERS CROSSING DR
LITHONIA GA
30058-7007
US

V. Phone/Fax

Practice location:
  • Phone: 470-971-2118
  • Fax:
Mailing address:
  • Phone: 678-993-7263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN242817
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN242817
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: