Provider Demographics
NPI:1265742290
Name:IYABOR, JOSEPHINE I
Entity type:Individual
Prefix:MRS
First Name:JOSEPHINE
Middle Name:I
Last Name:IYABOR
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 1:1191 FLAMINGO DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-6109
Mailing Address - Country:US
Mailing Address - Phone:770-778-2067
Mailing Address - Fax:770-732-6399
Practice Address - Street 1:1191 FLAMINGO DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-6109
Practice Address - Country:US
Practice Address - Phone:770-732-6366
Practice Address - Fax:770-732-6399
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172V00000X, 372600000X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
033012271OtherLICENSE NUMBER
GA263470342OtherTAX ID