Healthcare Provider Details

I. General information

NPI: 1356329411
Provider Name (Legal Business Name): MARY O EJIFOMA N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2006
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 N MAIN ST NW
KENNESAW GA
30144-2756
US

IV. Provider business mailing address

3369 BUFORD HIGHWAY SUITE 810
ATLANTA GA
30329-3722
US

V. Phone/Fax

Practice location:
  • Phone: 770-420-1092
  • Fax:
Mailing address:
  • Phone: 404-321-4692
  • Fax: 404-321-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN120872
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: