Healthcare Provider Details

I. General information

NPI: 1902637051
Provider Name (Legal Business Name): PROSPER C EMEKA NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WINN WAY
DECATUR GA
30030-1715
US

IV. Provider business mailing address

339 BLUE JUNIPER CIR
LOGANVILLE GA
30052-6539
US

V. Phone/Fax

Practice location:
  • Phone: 770-369-7248
  • Fax:
Mailing address:
  • Phone: 770-369-7248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN312074
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: