Provider Demographics
NPI:1245129097
Name:IFENDU, AGWU MANG
Entity type:Individual
Prefix:
First Name:AGWU
Middle Name:MANG
Last Name:IFENDU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8199 RHODES WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4086
Mailing Address - Country:US
Mailing Address - Phone:404-723-7341
Mailing Address - Fax:404-723-7341
Practice Address - Street 1:8199 RHODES WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4086
Practice Address - Country:US
Practice Address - Phone:404-723-7341
Practice Address - Fax:404-723-7341
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty