Healthcare Provider Details

I. General information

NPI: 1932702610
Provider Name (Legal Business Name): BISI M YINUSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PAPER CREEK DR
LAWRENCEVILLE GA
30046-5329
US

IV. Provider business mailing address

670 PAPER CREEK DR
LAWRENCEVILLE GA
30046-5329
US

V. Phone/Fax

Practice location:
  • Phone: 770-256-6542
  • Fax:
Mailing address:
  • Phone: 770-256-6542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN129580
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number129580
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: