Healthcare Provider Details

I. General information

NPI: 1417336249
Provider Name (Legal Business Name): ABIMBOLA OGUNNAIKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

1513 BROOKSTONE RD
HEPHZIBAH GA
30815-8912
US

V. Phone/Fax

Practice location:
  • Phone: 706-432-4889
  • Fax:
Mailing address:
  • Phone: 478-456-3173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN220112
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: