Provider Demographics
NPI:1003272824
Name:GEORGE, KORKOH-JAH MAMIEDEE (FNP)
Entity Type:Individual
Prefix:
First Name:KORKOH-JAH
Middle Name:MAMIEDEE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W 114TH ST APT 4D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2746
Mailing Address - Country:US
Mailing Address - Phone:646-320-2712
Mailing Address - Fax:
Practice Address - Street 1:306 W 114TH ST APT 4D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2746
Practice Address - Country:US
Practice Address - Phone:646-320-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33-337626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily