| Doctor Name: | MRS. GRACE M IBEANUSI |
| NPI Number: | 1366776924 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | FNPC |
| License Number: | RN118753 |
| Business Practice Address: | 195 Fairview Rd Ellenwood, GA - 302942722 |
| Business Phone Number: | 7705070112 |
| Business Fax Number: | 7705079450 |
| Mailing Address: | 4515 Investors Ln, ELLENWOOD |
| State: | GA |
| Postal Code: | 302946417 |
| Phone Number: | 7705070112 |
| Fax Number: | 7705079450 |
| NPI Enumeration Date: | 09/29/2009 |
| NPI Last Update Date: | 04/05/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | RN118753 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |