Provider Demographics
NPI:1477763654
Name:MBABA, EFIONG E (REGISTERED NURSE)
Entity Type:Individual
Prefix:MR
First Name:EFIONG
Middle Name:E
Last Name:MBABA
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 COMMERCE BLVD
Mailing Address - Street 2:SUITE A-32
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-3321
Mailing Address - Country:US
Mailing Address - Phone:770-907-0194
Mailing Address - Fax:770-907-0195
Practice Address - Street 1:804 COMMERCE BLVD
Practice Address - Street 2:SUITE A-32
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-3321
Practice Address - Country:US
Practice Address - Phone:770-907-0194
Practice Address - Fax:770-907-0195
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA06-19916332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5432230001Medicare NSC