Healthcare Provider Details

I. General information

NPI: 1396294237
Provider Name (Legal Business Name): BASIRAT SAID OWOLABI NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 ROSELANE ST NW
MARIETTA GA
30060-6940
US

IV. Provider business mailing address

613 ROSELANE ST NW
MARIETTA GA
30060-6940
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-9800
  • Fax: 770-794-7150
Mailing address:
  • Phone: 770-792-9800
  • Fax: 770-794-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN193411
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: