Healthcare Provider Details

I. General information

NPI: 1861703449
Provider Name (Legal Business Name): WILLIEMAE OKWANDU OWNER/ADMINISTRATOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. WILLIEMAE OKWANDU

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 BLACK DIAMOND DR
MCDONOUGH GA
30253-8822
US

IV. Provider business mailing address

818 BLACK DIAMOND DR
MCDONOUGH GA
30253-8822
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-4207
  • Fax: 770-474-4898
Mailing address:
  • Phone: 770-474-4207
  • Fax: 770-474-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number075-R-0740
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: