Provider Demographics
NPI:1528458270
Name:OGENDO, NANCY MIYUMO (CRNA)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:MIYUMO
Last Name:OGENDO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1635 OLD 41 HWY NW STE 112-328
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4480
Mailing Address - Country:US
Mailing Address - Phone:770-674-8626
Mailing Address - Fax:770-732-5182
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:770-674-8626
Practice Address - Fax:770-732-5182
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN232091367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered