Healthcare Provider Details

I. General information

NPI: 1053894618
Provider Name (Legal Business Name): GRACE OGHALE OSIEZAGHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE OGHALE GORDON HEALTH EDUCATOR M.ED

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5549 MCCROSSIN CIR
LITHONIA GA
30038-4801
US

IV. Provider business mailing address

5549 MCCROSSIN CIR
LITHONIA GA
30038-4801
US

V. Phone/Fax

Practice location:
  • Phone: 404-917-5112
  • Fax: 770-323-7512
Mailing address:
  • Phone: 404-917-5112
  • Fax: 770-323-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: