Provider Demographics
NPI:1083388748
Name:OUATTARA, GNIMBIN ALBERT
Entity Type:Individual
Prefix:
First Name:GNIMBIN
Middle Name:ALBERT
Last Name:OUATTARA
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 1:847 CONNERS CV
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6934
Mailing Address - Country:US
Mailing Address - Phone:404-543-3151
Mailing Address - Fax:
Practice Address - Street 1:847 CONNERS CV
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6934
Practice Address - Country:US
Practice Address - Phone:404-543-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP010651163WW0000X, 164W00000X, 251J00000X, 253Z00000X, 372600000X, 376K00000X, 385H00000X
GAPHCP01651374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care