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General NPI Number Information
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NPI Number | 1992142566
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Entity Type | Individual
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Provider Name | OMOTOLA ADUKE ADEBAYO NP
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Gender | Female
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Dates
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Enumeration Date | 05/23/2013
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Last Update Date | 03/12/2015
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Provider Practice Location Address
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Address Line | 106 RAM CAT ALY
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City | SENECA
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State | SC
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Zip | 29678-3244
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Country | US
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Telephone | 864-888-4445
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Fax | 864-888-4345
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Provider Business Mailing Address
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Address Line | 1774 BOXWOOD DR NW
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City | ACWORTH
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State | GA
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Zip | 30102-3579
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Country | US
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Telephone | 770-851-4003
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 18531
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number | RN
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License Number State | GA
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