Provider Demographics
NPI:1255126678
Name:EKHORUTOMWEN, IVIE B
Entity type:Individual
Prefix:
First Name:IVIE
Middle Name:B
Last Name:EKHORUTOMWEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 KENT CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8240
Mailing Address - Country:US
Mailing Address - Phone:413-204-4729
Mailing Address - Fax:
Practice Address - Street 1:110 WALTER WAY UNIT 2635
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9526
Practice Address - Country:US
Practice Address - Phone:404-692-0232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN296248363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health