Provider Demographics
NPI:1871123224
Name:MTUANWI, JOANNA NUKOABIA
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:NUKOABIA
Last Name:MTUANWI
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 1:2082 CHANNING DR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4164
Mailing Address - Country:US
Mailing Address - Phone:678-668-3152
Mailing Address - Fax:
Practice Address - Street 1:2082 CHANNING DR
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-4164
Practice Address - Country:US
Practice Address - Phone:678-668-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP0103973747A0650X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider