Healthcare Provider Details

I. General information

NPI: 1538894472
Provider Name (Legal Business Name): IFEOLUWA AKISANYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD
AUSTELL GA
30106-1121
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR
SANDY SPRINGS GA
30328-5831
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-4000
  • Fax:
Mailing address:
  • Phone: 770-874-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number113461
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: