Healthcare Provider Details

I. General information

NPI: 1902591472
Provider Name (Legal Business Name): NIMBA INTEGRATIVE PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MEMORIAL DR STE 101
STONE MOUNTAIN GA
30083-3154
US

IV. Provider business mailing address

5300 MEMORIAL DR STE 101
STONE MOUNTAIN GA
30083-3154
US

V. Phone/Fax

Practice location:
  • Phone: 470-918-9719
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. ASATA KAMARA APRN
Title or Position: OWNER
Credential: ASATA KAMARA DNP
Phone: 470-918-9719