Provider Demographics
NPI:1457081705
Name:NDUNGU, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NDUNGU
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 1:3190 CRESTMONT WAY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4682
Mailing Address - Country:US
Mailing Address - Phone:404-931-1382
Mailing Address - Fax:
Practice Address - Street 1:3190 CRESTMONT WAY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4682
Practice Address - Country:US
Practice Address - Phone:404-931-1382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA297005163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health