Provider Demographics
NPI:1073074506
Name:ANYANWU, KELECHUKWU C (DO)
Entity type:Individual
Prefix:
First Name:KELECHUKWU
Middle Name:C
Last Name:ANYANWU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELECHUKWU
Other - Middle Name:C
Other - Last Name:ONYEDIMMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1790 PRESIDENTIAL CIR STE C
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5688
Mailing Address - Country:US
Mailing Address - Phone:404-251-4890
Mailing Address - Fax:
Practice Address - Street 1:1790 PRESIDENTIAL CIR STE C
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5688
Practice Address - Country:US
Practice Address - Phone:404-251-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA921462083P0901X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA92146OtherGA MEDICAL LICENSE