=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811662323
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA KIKANWA IBUDE RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2021
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1607 BARRINGTON VW
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30087-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-702-9821
-----------------------------------------------------
Fax | 678-705-3735
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4942 BERKELEY OAK CIR
-----------------------------------------------------
City | PEACHTREE CORNERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-4959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-916-9641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN254977
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------