Healthcare Provider Details

I. General information

NPI: 1366314213
Provider Name (Legal Business Name): KELECHI RUTH UKEGBU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2025
Last Update Date: 09/20/2025
Certification Date: 09/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5270 E FAIRVIEW RD SW
STOCKBRIDGE GA
30281-5335
US

IV. Provider business mailing address

5270 E FAIRVIEW RD SW
STOCKBRIDGE GA
30281-5335
US

V. Phone/Fax

Practice location:
  • Phone: 470-779-2545
  • Fax:
Mailing address:
  • Phone: 470-779-2545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP284853
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: