=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417779109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH FEHINTOLA OLUGBUSI FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2024
-----------------------------------------------------
Last Update Date | 10/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 745 GLYNN ST S
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-719-5490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 745 GLYNN ST S
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | RN319946
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------