Healthcare Provider Details

I. General information

NPI: 1760350136
Provider Name (Legal Business Name): ADEBISI OMOLARA OGUNYEMI AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ALTAMONTE DR
ALTAMONTE SPRINGS FL
32701-4802
US

IV. Provider business mailing address

574 WOODFORD DR
DEBARY FL
32713-2123
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-8780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN11043215
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: