Healthcare Provider Details

I. General information

NPI: 1104174531
Provider Name (Legal Business Name): MAMBOH NGUM YUFENYUY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 SOUTHGATE MILL DR NW
DULUTH GA
30096
US

IV. Provider business mailing address

1657 SOUTHGATE MILL DR NW
DULUTH GA
30096-8837
US

V. Phone/Fax

Practice location:
  • Phone: 678-977-5976
  • Fax:
Mailing address:
  • Phone: 678-977-5976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number17691
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN188604
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN188604
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: