Provider Demographics
NPI:1053807347
Name:IBETO, KEN
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:IBETO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KENECHUKWU
Other - Middle Name:IKECHUKWU
Other - Last Name:IBETO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7646 FOREST GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-6867
Mailing Address - Country:US
Mailing Address - Phone:678-637-6249
Mailing Address - Fax:404-393-4950
Practice Address - Street 1:7646 FOREST GLEN WAY
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-6867
Practice Address - Country:US
Practice Address - Phone:678-637-6249
Practice Address - Fax:404-393-4950
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048-R-2014364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health