Healthcare Provider Details

I. General information

NPI: 1649787102
Provider Name (Legal Business Name): JUDITH FUAJONG NGULEFAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1766 LAWRENCEVILLE HWY
DECATUR GA
30033-5641
US

IV. Provider business mailing address

1766 LAWRENCEVILLE HWY
DECATUR GA
30033-5641
US

V. Phone/Fax

Practice location:
  • Phone: 470-746-3142
  • Fax: 404-478-8864
Mailing address:
  • Phone: 470-746-3142
  • Fax: 404-478-8864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN189589
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN189589
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN189589
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: