Provider Demographics
NPI:1326331042
Name:IBELEMA, DANIELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:
Last Name:IBELEMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4062 PEACHTREE RD NE STE A-536
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3021
Mailing Address - Country:US
Mailing Address - Phone:678-827-5797
Mailing Address - Fax:
Practice Address - Street 1:4062 PEACHTREE RD NE STE A-536
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3021
Practice Address - Country:US
Practice Address - Phone:678-322-8138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0762632080A0000X
GA762632084P0800X, 2084P0804X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA076263OtherMEDICAL LICENSE