Provider Demographics
NPI:1760603757
Name:SAINT JUSTE, UDUAK ETIM
Entity Type:Individual
Prefix:
First Name:UDUAK
Middle Name:ETIM
Last Name:SAINT JUSTE
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 1:100 LACY ST NW STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1273
Mailing Address - Country:US
Mailing Address - Phone:770-793-7635
Mailing Address - Fax:
Practice Address - Street 1:100 LACY ST NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1271
Practice Address - Country:US
Practice Address - Phone:770-793-7635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3071363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI157166OtherLICENSE