Provider Demographics
NPI:1871703033
Name:MOMOH, ISATA C (NP-C)
Entity type:Individual
Prefix:MS
First Name:ISATA
Middle Name:C
Last Name:MOMOH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2675 N DECATUR RD
Mailing Address - Street 2:410
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-501-2927
Mailing Address - Fax:404-501-7644
Practice Address - Street 1:2855 ADAMS POINTE DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2930
Practice Address - Country:US
Practice Address - Phone:770-978-5032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN136010363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA146007449AMedicaid