Healthcare Provider Details

I. General information

NPI: 1558943076
Provider Name (Legal Business Name): MABEL ASARE FOSU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

5960 WESTCROFT LN
CUMMING GA
30040-1236
US

V. Phone/Fax

Practice location:
  • Phone: 678-209-2394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number282408
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: