Provider Demographics
NPI:1356329411
Name:EJIFOMA, MARY O (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:O
Last Name:EJIFOMA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3369 BUFORD HIGHWAY
Mailing Address - Street 2:SUITE 810
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3722
Mailing Address - Country:US
Mailing Address - Phone:404-321-4692
Mailing Address - Fax:404-321-4366
Practice Address - Street 1:3070 N MAIN ST NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2756
Practice Address - Country:US
Practice Address - Phone:770-420-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-08
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN120872363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBJZTMedicare UPIN