Provider Demographics
NPI:1629561345
Name:EKE, GRACE ADA NDUKA
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ADA NDUKA
Last Name:EKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 W GORDON ST
Mailing Address - Street 2:STE A
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3480
Mailing Address - Country:US
Mailing Address - Phone:678-357-9861
Mailing Address - Fax:
Practice Address - Street 1:405 HILLSDALE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1468
Practice Address - Country:US
Practice Address - Phone:678-357-9861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN228096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily