MEDICARE: OLASUMBO OLUWAKEMI DADA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN186907	GA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN186907	GA

General Provider Information

NPI Number	:	1477806461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLASUMBO OLUWAKEMI DADA

Provider Business Mailing Address
First Line	:	30 MEADOW VALLEY CT
Second Line	:
City	:	MIDLAND
State	:	GA
Zip	:	31820-4393
Country	:	US
Telephone Number	:	719-231-9213
Fax Number	:

Provider Business Practice Location Address
First Line	:	MACH
Second Line	:	6600 VAN AALST BLVD
City	:	FT. MOORE
State	:	GA
Zip	:	31905
Country	:	US
Telephone Number	:	719-231-9213
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2012
Last Update Date	:	02/12/2025

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