Provider Demographics
NPI:1730604620
Name:OTALUKA, NNENNA BEATRICE (NP)
Entity type:Individual
Prefix:
First Name:NNENNA
Middle Name:BEATRICE
Last Name:OTALUKA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5329 MEMORIAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3212
Mailing Address - Country:US
Mailing Address - Phone:404-296-7695
Mailing Address - Fax:404-296-7696
Practice Address - Street 1:5329 MEMORIAL DR STE A
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3212
Practice Address - Country:US
Practice Address - Phone:404-296-7695
Practice Address - Fax:404-296-7695
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN152070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily