Healthcare Provider Details

I. General information

NPI: 1699476796
Provider Name (Legal Business Name): OLUBUKOLA OLOTU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1784 BROOKSTONE CT NW
ACWORTH GA
30101-4562
US

IV. Provider business mailing address

1784 BROOKSTONE CT NW
ACWORTH GA
30101-4562
US

V. Phone/Fax

Practice location:
  • Phone: 872-212-7240
  • Fax:
Mailing address:
  • Phone: 872-212-7240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9627720
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN100801
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043.131119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: