Provider Demographics
NPI:1164121281
Name:OKONGWU, CLEMENT C
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:C
Last Name:OKONGWU
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 1:867 GRAMERCY HILLS LN
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-7250
Mailing Address - Country:US
Mailing Address - Phone:551-208-4703
Mailing Address - Fax:
Practice Address - Street 1:867 GRAMERCY HILLS LN
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-7250
Practice Address - Country:US
Practice Address - Phone:551-208-4703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2022139428363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health