Provider Demographics
NPI:1629692165
Name:VADAKKEDAM, JOFFY S
Entity Type:Individual
Prefix:
First Name:JOFFY
Middle Name:S
Last Name:VADAKKEDAM
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 1:1990 TRIBBLE WALK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3483
Mailing Address - Country:US
Mailing Address - Phone:609-598-1236
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:678-209-2394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA090341164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse