Healthcare Provider Details

I. General information

NPI: 1871320440
Provider Name (Legal Business Name): ISAAC CHIKODI OGBUAGU DNP PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7009 BLACKBERRY DR
GROVETOWN GA
30813-8209
US

IV. Provider business mailing address

1 FREEDOM WAY # 2G
AUGUSTA GA
30904-6258
US

V. Phone/Fax

Practice location:
  • Phone: 404-937-9669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN284857
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: