Healthcare Provider Details

I. General information

NPI: 1760603757
Provider Name (Legal Business Name): UDUAK ETIM SAINT JUSTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LACY ST NW
MARIETTA GA
30060-1271
US

IV. Provider business mailing address

100 LACY ST NW STE 150
MARIETTA GA
30060-1273
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-7635
  • Fax:
Mailing address:
  • Phone: 770-793-7635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3071
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: