Healthcare Provider Details

I. General information

NPI: 1750731980
Provider Name (Legal Business Name): PATIENCE OGAGA-MGBONYEBI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 06/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 SILHOUETTE LN SW
MABLETON GA
30126-2239
US

IV. Provider business mailing address

PO BOX 222
MABLETON GA
30126-0222
US

V. Phone/Fax

Practice location:
  • Phone: 404-543-9778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number163490
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: