Provider Demographics
NPI:1154133957
Name:OMONUA, IDANESI NACOLE
Entity type:Individual
Prefix:
First Name:IDANESI
Middle Name:NACOLE
Last Name:OMONUA
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 1:8619 THOMAS LN # A
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-5196
Mailing Address - Country:US
Mailing Address - Phone:470-827-2022
Mailing Address - Fax:
Practice Address - Street 1:3190 NORTHEAST EXPY NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:470-827-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst