Healthcare Provider Details

I. General information

NPI: 1093950545
Provider Name (Legal Business Name): ABOSEDE A OSHINUBI RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 LAWRENCEVILLE HWY NW SUITE A
LILBURN GA
30047-2819
US

IV. Provider business mailing address

944 LIBERTY IVES DR
AUBURN GA
30011-2274
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-7007
  • Fax:
Mailing address:
  • Phone: 678-516-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberLD002267
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002267
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLD002267
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD002267
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: