Healthcare Provider Details

I. General information

NPI: 1659073617
Provider Name (Legal Business Name): BABAJIDE OGUNYOMBO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11353 FLAME WILLOW LN
KNOXVILLE TN
37932-3624
US

IV. Provider business mailing address

11353 FLAME WILLOW LN
KNOXVILLE TN
37932-3624
US

V. Phone/Fax

Practice location:
  • Phone: 865-306-7492
  • Fax:
Mailing address:
  • Phone: 865-306-7492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0000030236
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: