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General NPI Number Information
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NPI Number | 1366776924
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Entity Type | Individual
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Provider Name | GRACE NWACHUKWU IBEANUSI NP
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Gender | Female
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Dates
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Enumeration Date | 09/29/2009
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Last Update Date | 03/29/2021
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Provider Practice Location Address
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Address Line | 896 HIGHWAY 81 E
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City | MCDONOUGH
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State | GA
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Zip | 30252-2914
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Country | US
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Telephone | 678-732-1520
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 102038
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City | ATLANTA
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State | GA
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Zip | 30368-2038
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN118753
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License Number State | GA
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