Provider Demographics
NPI:1801487293
Name:IMAFIDON, SUNDAY
Entity type:Individual
Prefix:MR
First Name:SUNDAY
Middle Name:
Last Name:IMAFIDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S 8TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4260
Mailing Address - Country:US
Mailing Address - Phone:770-229-6072
Mailing Address - Fax:
Practice Address - Street 1:619 S 8TH ST STE 301
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4260
Practice Address - Country:US
Practice Address - Phone:770-229-6072
Practice Address - Fax:770-229-2111
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily