Healthcare Provider Details

I. General information

NPI: 1245928456
Provider Name (Legal Business Name): OLUABO EDOGIAWERIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 ESTATE VIEW CT
DACULA GA
30019-4015
US

IV. Provider business mailing address

3008 ESTATE VIEW CT
DACULA GA
30019-4015
US

V. Phone/Fax

Practice location:
  • Phone: 708-539-1638
  • Fax:
Mailing address:
  • Phone: 708-539-1638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN280906
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN280906
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: