Healthcare Provider Details

I. General information

NPI: 1821356775
Provider Name (Legal Business Name): MRS. NNEAMAKA ANITA IFECHUKWUDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NNEAMAKA ANITA UGBODE

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTHSIDE FORSYTH DR
CUMMING GA
30041-7659
US

IV. Provider business mailing address

6325 HOSPITAL PKWY
JOHNS CREEK GA
30097-5775
US

V. Phone/Fax

Practice location:
  • Phone: 770-844-3200
  • Fax: 770-844-3227
Mailing address:
  • Phone: 404-778-5361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number074694
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: