Provider Demographics
NPI:1184325862
Name:AMOUSSA MADJIBI, LIMATA AYINKE
Entity type:Individual
Prefix:
First Name:LIMATA
Middle Name:AYINKE
Last Name:AMOUSSA MADJIBI
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 1:1543 SOONER CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6618
Mailing Address - Country:US
Mailing Address - Phone:770-402-0966
Mailing Address - Fax:
Practice Address - Street 1:3915 CASCADE RD SW STE 360
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8533
Practice Address - Country:US
Practice Address - Phone:678-973-2370
Practice Address - Fax:470-819-4995
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN274105363LP0808X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health