Provider Demographics
NPI:1053894618
Name:OSIEZAGHA, GRACE OGHALE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:OGHALE
Last Name:OSIEZAGHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:OGHALE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HEALTH EDUCATOR MED
Mailing Address - Street 1:5549 MCCROSSIN CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4801
Mailing Address - Country:US
Mailing Address - Phone:404-917-5112
Mailing Address - Fax:770-323-7512
Practice Address - Street 1:5549 MCCROSSIN CIR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-4801
Practice Address - Country:US
Practice Address - Phone:404-917-5112
Practice Address - Fax:770-323-7512
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X, 172V00000X, 174H00000X, 175T00000X, 251S00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No175T00000XOther Service ProvidersPeer Specialist
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1066260OtherHEALTH EDUCATION
GACN0028834263OtherCNA
GA886674697OtherNASW
GA263534OtherBFTS