Provider Demographics
NPI:1114456316
Name:EKPOUDOM, MERCY A (RN)
Entity Type:Individual
Prefix:MRS
First Name:MERCY
Middle Name:A
Last Name:EKPOUDOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:EDNA
Other - Middle Name:I
Other - Last Name:AMASOWOMWAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:305 SAINT PAULS CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-1093
Mailing Address - Country:US
Mailing Address - Phone:678-608-7151
Mailing Address - Fax:678-289-9256
Practice Address - Street 1:305 SAINT PAULS CT
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-1093
Practice Address - Country:US
Practice Address - Phone:678-608-7151
Practice Address - Fax:678-289-9256
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN109319163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN109319OtherNURSING LICENSE NO