MEDICARE: OWA I OYIBO RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN199711	GA

General Provider Information

NPI Number	:	1346079571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OWA I OYIBO RN

Provider Business Mailing Address
First Line	:	3130 ROCK MANOR WAY
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-7698
Country	:	US
Telephone Number	:	770-337-6778
Fax Number	:

Provider Business Practice Location Address
First Line	:	3130 ROCK MANOR WAY
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30519-7698
Country	:	US
Telephone Number	:	770-337-6778
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2024
Last Update Date	:	07/27/2024

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