Healthcare Provider Details

I. General information

NPI: 1982254330
Provider Name (Legal Business Name): ESI CUDJOE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 NEWNAN CROSSING BYP STE 200
NEWNAN GA
30265-2434
US

IV. Provider business mailing address

900 CIRCLE 75 PKWY SE STE 1700
ATLANTA GA
30339-3087
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-4747
  • Fax:
Mailing address:
  • Phone: 770-953-6929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN204222
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: