Healthcare Provider Details

I. General information

NPI: 1609423086
Provider Name (Legal Business Name): IFEYINWA DORIS OTIJI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

1206 YELLOW RIVER DR
LAWRENCEVILLE GA
30043-8499
US

V. Phone/Fax

Practice location:
  • Phone: 678-209-2394
  • Fax:
Mailing address:
  • Phone: 301-237-6976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN091988
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: