Healthcare Provider Details

I. General information

NPI: 1861040479
Provider Name (Legal Business Name): OLADUNNI FUNMI FAMINU FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 CARPENTER DR STE 310
ATLANTA GA
30328-4911
US

IV. Provider business mailing address

2701 N DECATUR RD # 2400
DECATUR GA
30033-5918
US

V. Phone/Fax

Practice location:
  • Phone: 844-403-4325
  • Fax:
Mailing address:
  • Phone: 770-617-7493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN214882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: