Healthcare Provider Details

I. General information

NPI: 1255623831
Provider Name (Legal Business Name): TITILAYO TIAMIYU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 WHITTLESEY BLVD APT 1007
COLUMBUS GA
31909-7261
US

IV. Provider business mailing address

1046 RIDGE AVE SW
ATLANTA GA
30315-1640
US

V. Phone/Fax

Practice location:
  • Phone: 706-221-2930
  • Fax: 706-221-2930
Mailing address:
  • Phone: 404-688-1350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN201670
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN201670
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: