Healthcare Provider Details

I. General information

NPI: 1851625602
Provider Name (Legal Business Name): OLIVIA NGOZI MGBEOKWERE MS, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE STE 1D03
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

1670 CLAIRMONT RD STE 5
DECATUR GA
30033-4004
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6633
  • Fax:
Mailing address:
  • Phone: 404-321-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 113001 NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: