Provider Demographics
NPI:1629705314
Name:MBELE, MUDIWA IRENE FAYE HOGAN
Entity Type:Individual
Prefix:
First Name:MUDIWA
Middle Name:IRENE FAYE HOGAN
Last Name:MBELE
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 1:3132 SPICY CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-7161
Mailing Address - Country:US
Mailing Address - Phone:678-508-1935
Mailing Address - Fax:
Practice Address - Street 1:2910 EVANS MILL RD STE B-334
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2481
Practice Address - Country:US
Practice Address - Phone:404-207-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000929277BMedicaid