Healthcare Provider Details

I. General information

NPI: 1609640580
Provider Name (Legal Business Name): JOY IJEOMA EZEOKONKWO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 REBECCA ST NW
LILBURN GA
30047-8730
US

IV. Provider business mailing address

853 REBECCA ST NW
LILBURN GA
30047-8730
US

V. Phone/Fax

Practice location:
  • Phone: 404-502-8594
  • Fax:
Mailing address:
  • Phone: 404-502-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN156531
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: