Healthcare Provider Details

I. General information

NPI: 1700587961
Provider Name (Legal Business Name): LOLA OGUNNIYI PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 MONTREAL RD STE 111
TUCKER GA
30084-5712
US

IV. Provider business mailing address

3050 FIVE FORKS TRICKUM RD SW STE D454
LILBURN GA
30047-1810
US

V. Phone/Fax

Practice location:
  • Phone: 404-725-8455
  • Fax:
Mailing address:
  • Phone: 470-871-9105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN307055
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: