Provider Demographics
NPI:1215633912
Name:DAFIVBIRORO, EMMANUEL D (APRN)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:D
Last Name:DAFIVBIRORO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6297 ROBINS TRCE
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6537
Mailing Address - Country:US
Mailing Address - Phone:770-413-1424
Mailing Address - Fax:
Practice Address - Street 1:6297 ROBINS TRCE
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-6537
Practice Address - Country:US
Practice Address - Phone:770-413-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN154440363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care