Provider Demographics
NPI:1134703705
Name:AZIAMADJI, KODJO VIVIEN
Entity Type:Individual
Prefix:
First Name:KODJO
Middle Name:VIVIEN
Last Name:AZIAMADJI
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 1:1477 ROGERS CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7007
Mailing Address - Country:US
Mailing Address - Phone:678-993-7263
Mailing Address - Fax:
Practice Address - Street 1:6238 TURNER LAKE RD SW
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-3057
Practice Address - Country:US
Practice Address - Phone:470-971-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242817163WE0003X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1134703705Medicaid