Provider Demographics
NPI:1811455488
Name:UBOM, INIMFON E
Entity type:Individual
Prefix:
First Name:INIMFON
Middle Name:E
Last Name:UBOM
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 1:535 GROVE PARK PL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-6873
Mailing Address - Country:US
Mailing Address - Phone:470-383-9999
Mailing Address - Fax:
Practice Address - Street 1:535 GROVE PARK PL
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-6873
Practice Address - Country:US
Practice Address - Phone:470-383-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC006204367500000X
TN29624367500000X
390200000X
GARN202032367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program