Healthcare Provider Details

I. General information

NPI: 1811693971
Provider Name (Legal Business Name): STELLA OLUCHI OKIBEDI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 CHARLES HARDY PKWY
DALLAS GA
30157-5723
US

IV. Provider business mailing address

495 CHARLES HARDY PKWY
DALLAS GA
30157-5723
US

V. Phone/Fax

Practice location:
  • Phone: 770-445-2128
  • Fax:
Mailing address:
  • Phone: 770-445-2128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number205567
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number205567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: