Healthcare Provider Details

I. General information

NPI: 1841017944
Provider Name (Legal Business Name): OLABISI FASHUYI FAFORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2024
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 LAKEFIELD DR
JOHNS CREEK GA
30097-1714
US

IV. Provider business mailing address

1183 LANIER SPRINGS DR
BUFORD GA
30518-7272
US

V. Phone/Fax

Practice location:
  • Phone: 470-242-6344
  • Fax:
Mailing address:
  • Phone: 612-227-4763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN297527
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ15240800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: