=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629947247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NNEAMAKA IFEADIKE
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2025
-----------------------------------------------------
Last Update Date | 11/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 PILGRIM VILLAGE DR STE 200
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30040-2583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-395-3269
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11130 MEDLOCK BRIDGE RD APT 1110
-----------------------------------------------------
City | JOHNS CREEK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-8502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-567-6214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP013059
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------