Basic Information
| Provider Information | |||||||||
| NPI: | 1598289860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBIAM | ||||||||
| FirstName: | CHINWE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1885 SILVERSTONE DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300457273 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 766 WALTHER RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707366300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2017 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | RN217527 | GA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 363LA2100X | RN217527 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LP0808X | 5012244 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.