Provider Demographics
NPI:1124669403
Name:MIKIE, EBUNOLUWA
Entity type:Individual
Prefix:
First Name:EBUNOLUWA
Middle Name:
Last Name:MIKIE
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 1:1800 HOG MOUNTAIN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-1935
Mailing Address - Country:US
Mailing Address - Phone:770-554-2999
Mailing Address - Fax:
Practice Address - Street 1:1800 HOG MOUNTAIN RD STE 101
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-1935
Practice Address - Country:US
Practice Address - Phone:770-554-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230157363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health