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General NPI Number Information
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NPI Number | 1568022671
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Entity Type | Individual
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Provider Name | OLIVIA T AGBOOLA
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Gender | Female
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Dates
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Enumeration Date | 06/20/2019
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Last Update Date | 06/20/2019
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Provider Practice Location Address
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Address Line | 135 HENRY PKWY
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City | MCDONOUGH
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State | GA
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Zip | 30253-6636
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Country | US
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Telephone | 770-288-6155
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Fax | 770-954-2269
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Provider Business Mailing Address
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Address Line | 4001 S RIVER LN
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City | ELLENWOOD
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State | GA
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Zip | 30294-3293
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Country | US
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Telephone | 678-357-6069
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN209875
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License Number State | GA
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