Provider Demographics
NPI:1578390464
Name:MBADIWE, NNEKA (MSN)
Entity type:Individual
Prefix:
First Name:NNEKA
Middle Name:
Last Name:MBADIWE
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WATERS EDGE WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8510
Mailing Address - Country:US
Mailing Address - Phone:770-412-2104
Mailing Address - Fax:
Practice Address - Street 1:121 WATERS EDGE WAY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-8510
Practice Address - Country:US
Practice Address - Phone:770-412-2104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA247515363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty