Healthcare Provider Details

I. General information

NPI: 1770149767
Provider Name (Legal Business Name): OGONNAYA IFEADIKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 GRESHAM DR
NORFOLK VA
23507
US

IV. Provider business mailing address

720 WESTVIEW DR SW
ATLANTA GA
30310-1458
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101282725
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number92124
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: