Healthcare Provider Details

I. General information

NPI: 1063233104
Provider Name (Legal Business Name): UBI OKIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HERRELL RD
VILLA RICA GA
30180
US

IV. Provider business mailing address

20 HERRELL RD
VILLA RICA GA
30180-5527
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-3530
  • Fax: 770-812-3531
Mailing address:
  • Phone: 770-812-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP152608
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: