Provider Demographics
NPI:1649622952
Name:NWAISE, NGOZI DOREEN
Entity type:Individual
Prefix:MRS
First Name:NGOZI
Middle Name:DOREEN
Last Name:NWAISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 MCCONNELL RUN XING
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-7804
Mailing Address - Country:US
Mailing Address - Phone:678-467-6010
Mailing Address - Fax:
Practice Address - Street 1:780 MCCONNELL RUN XING
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-7804
Practice Address - Country:US
Practice Address - Phone:678-467-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN188872363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner