Healthcare Provider Details

I. General information

NPI: 1063032340
Provider Name (Legal Business Name): IJEOMA JACINTA NNANABU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 FAIR RD
STATESBORO GA
30458-1683
US

IV. Provider business mailing address

1499 FAIR RD
STATESBORO GA
30458-1683
US

V. Phone/Fax

Practice location:
  • Phone: 912-486-1431
  • Fax:
Mailing address:
  • Phone: 912-486-1431
  • Fax: 912-871-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number96992
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: