Provider Demographics
NPI:1194466607
Name:IDUBOR, IMOSE (NP)
Entity Type:Individual
Prefix:MRS
First Name:IMOSE
Middle Name:
Last Name:IDUBOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 IVEY CHASE PL
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7866
Mailing Address - Country:US
Mailing Address - Phone:678-670-9626
Mailing Address - Fax:
Practice Address - Street 1:1067 IVEY CHASE PL
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7866
Practice Address - Country:US
Practice Address - Phone:678-670-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN261495363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health