Healthcare Provider Details

I. General information

NPI: 1033595566
Provider Name (Legal Business Name): OMOLOLA OTUBAGA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BECKETT LN STE. 304
FAYETTEVILLE GA
30214-7155
US

IV. Provider business mailing address

5465 HIGHWAY 42 246
ELLENWOOD GA
30294-3928
US

V. Phone/Fax

Practice location:
  • Phone: 770-703-4448
  • Fax: 770-703-4038
Mailing address:
  • Phone: 470-646-3738
  • Fax: 888-910-6463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN207871
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: