Provider Demographics
NPI:1992080436
Name:IDUSUYI, ESOHE GRACE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:ESOHE
Middle Name:GRACE
Last Name:IDUSUYI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4944 SEPTEMBER COURT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102
Mailing Address - Country:US
Mailing Address - Phone:770-975-9538
Mailing Address - Fax:
Practice Address - Street 1:4944 SEPTEMBER CT NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-7915
Practice Address - Country:US
Practice Address - Phone:770-975-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN144525NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily