Provider Demographics
NPI:1184257404
Name:IBEZIM, SCHOLAR
Entity type:Individual
Prefix:
First Name:SCHOLAR
Middle Name:
Last Name:IBEZIM
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 1:2272 AZALEA DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-2653
Mailing Address - Country:US
Mailing Address - Phone:770-680-4340
Mailing Address - Fax:
Practice Address - Street 1:2272 AZALEA DR STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-2653
Practice Address - Country:US
Practice Address - Phone:770-680-4340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA138544163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice