Healthcare Provider Details

I. General information

NPI: 1790304020
Provider Name (Legal Business Name): ADETOLA OLOBATUYI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

1436 HAYNES TRACE CT
GRAYSON GA
30017-2898
US

V. Phone/Fax

Practice location:
  • Phone: 678-209-2394
  • Fax:
Mailing address:
  • Phone: 770-744-6850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN166394
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: