=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033844998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMOYEME ALICESON EHIZUELEN APRN, PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2022
-----------------------------------------------------
Last Update Date | 08/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 HILLCREST RD NW STE 400
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-6898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-566-8045
-----------------------------------------------------
Fax | 404-999-6787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 NORTHSIDE DRIVE NW SUITE A7 PMB 2078
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-566-8045
-----------------------------------------------------
Fax | 404-999-6787
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN313937
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 313937
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------