Provider Demographics
NPI:1558960245
Name:DIYOMBI, AVELIN M
Entity Type:Individual
Prefix:
First Name:AVELIN
Middle Name:M
Last Name:DIYOMBI
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 1:113 VILLAGE PL
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5708
Mailing Address - Country:US
Mailing Address - Phone:678-378-7596
Mailing Address - Fax:
Practice Address - Street 1:113 VILLAGE PL
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5708
Practice Address - Country:US
Practice Address - Phone:678-378-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061126829172A00000X
GACN0030061735376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No172A00000XOther Service ProvidersDriver