Provider Demographics
NPI:1861703449
Name:OKWANDU, WILLIEMAE (OWNER/ADMINISTRATOR)
Entity type:Individual
Prefix:MRS
First Name:WILLIEMAE
Middle Name:
Last Name:OKWANDU
Suffix:
Gender:F
Credentials:OWNER/ADMINISTRATOR
Other - Prefix:MRS
Other - First Name:WILLIEMAE
Other - Middle Name:
Other - Last Name:OKWANDU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:818 BLACK DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8822
Mailing Address - Country:US
Mailing Address - Phone:770-474-4207
Mailing Address - Fax:770-474-4898
Practice Address - Street 1:818 BLACK DIAMOND DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8822
Practice Address - Country:US
Practice Address - Phone:770-474-4207
Practice Address - Fax:770-474-4898
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075-R-0740251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health