Provider Demographics
NPI:1215619747
Name:ENADEGHE, TAIYE
Entity type:Individual
Prefix:
First Name:TAIYE
Middle Name:
Last Name:ENADEGHE
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 1:5173 ROSEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-5116
Mailing Address - Country:US
Mailing Address - Phone:770-217-0922
Mailing Address - Fax:866-277-9769
Practice Address - Street 1:5173 ROSEWOOD PL
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-5116
Practice Address - Country:US
Practice Address - Phone:770-217-0922
Practice Address - Fax:866-277-9769
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN294155163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse