Provider Demographics
NPI:1982899761
Name:BOTAH-ODURO, OPHELIA A (DNP, FNP-C)
Entity Type:Individual
Prefix:DR
First Name:OPHELIA
Middle Name:A
Last Name:BOTAH-ODURO
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5095 MOUNT ZION PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7825
Mailing Address - Country:US
Mailing Address - Phone:770-507-0576
Mailing Address - Fax:
Practice Address - Street 1:5095 MOUNT ZION PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7825
Practice Address - Country:US
Practice Address - Phone:770-507-0576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN145040363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I503862Medicare PIN