Imose Idubor, NP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

RN261495 Issued in GA

Practice address

1067 Ivey Chase PL
Dacula, GA 30019-7866

Phone

(678) 670-9626

NPI assigned

Apr 6, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Nurse Practitioner

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1649203200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1649635200000",
    "number": "1194466607",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1067 IVEY CHASE PL",
            "city": "DACULA",
            "state": "GA",
            "postal_code": "300197866",
            "telephone_number": "678-670-9626"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1067 IVEY CHASE PL",
            "city": "DACULA",
            "state": "GA",
            "postal_code": "300197866",
            "telephone_number": "678-670-9626"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IDUBOR",
        "first_name": "IMOSE",
        "name_prefix": "Mrs.",
        "credential": "NP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-04-06",
        "last_updated": "2022-04-11",
        "certification_date": "2022-04-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "GA",
            "license": "RN261495",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Integrative Medical Management Group

• All providers in Dacula, GA
• Psychiatric/Mental Health Nurse Practitioner in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.