MEDICARE: FATIMAT OLUMAYOWA OLUFUNMILAYO AGBOJEYIN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	177491	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477189157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATIMAT OLUMAYOWA OLUFUNMILAYO AGBOJEYIN

Provider Business Mailing Address
First Line	:	105 EMERALD LAKE CT
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30215-7748
Country	:	US
Telephone Number	:	404-513-2868
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 EMERALD LAKE CT
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30215-7748
Country	:	US
Telephone Number	:	404-513-2868
Fax Number	:

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

Provider Enumeration Date	:	03/13/2020
Last Update Date	:	03/13/2020

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