Healthcare Provider Details

I. General information

NPI: 1831693357
Provider Name (Legal Business Name): BAMIDELE ODEDE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY
DECATUR GA
30030
US

IV. Provider business mailing address

2100 VALLEY CREEK DR
LITHIA SPRINGS GA
30122-3647
US

V. Phone/Fax

Practice location:
  • Phone: 404-294-3835
  • Fax:
Mailing address:
  • Phone: 443-527-8356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5010392
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN213970
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: