Healthcare Provider Details

I. General information

NPI: 1134998289
Provider Name (Legal Business Name): JANE OMUVWIE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2023
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4499 BRIDLE RIDGE WAY
LITHONIA GA
30038-6520
US

IV. Provider business mailing address

4499 BRIDLE RIDGE WAY
LITHONIA GA
30038-6520
US

V. Phone/Fax

Practice location:
  • Phone: 310-502-5144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number107035
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: