Healthcare Provider Details

I. General information

NPI: 1801487293
Provider Name (Legal Business Name): MR. SUNDAY IMAFIDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S 8TH ST STE 301
GRIFFIN GA
30224-4260
US

IV. Provider business mailing address

619 S 8TH ST STE 301
GRIFFIN GA
30224-4260
US

V. Phone/Fax

Practice location:
  • Phone: 770-229-6072
  • Fax: 770-229-2111
Mailing address:
  • Phone: 770-229-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN230604
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: