Healthcare Provider Details

I. General information

NPI: 1194466607
Provider Name (Legal Business Name): IMOSE IDUBOR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1067 IVEY CHASE PL
DACULA GA
30019-7866
US

IV. Provider business mailing address

1067 IVEY CHASE PL
DACULA GA
30019-7866
US

V. Phone/Fax

Practice location:
  • Phone: 678-670-9626
  • Fax:
Mailing address:
  • Phone: 678-670-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN261495
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: