Healthcare Provider Details

I. General information

NPI: 1154876415
Provider Name (Legal Business Name): AYOOLA FADEYI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 11/05/2024
Certification Date: 08/07/2020
Deactivation Date: 08/07/2020
Reactivation Date: 11/05/2024

III. Provider practice location address

1446 BELLSMITH DR
ROSWELL GA
30076-0921
US

IV. Provider business mailing address

1446 BELLSMITH DR
ROSWELL GA
30076-0921
US

V. Phone/Fax

Practice location:
  • Phone: 917-445-2420
  • Fax:
Mailing address:
  • Phone: 917-445-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number055852853
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number34147
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: