Provider Demographics
NPI:1548685217
Name:IGUNBOR, OLUWADAMILOLA A (RN, BSN, MSN, AGPCNP)
Entity type:Individual
Prefix:
First Name:OLUWADAMILOLA
Middle Name:A
Last Name:IGUNBOR
Suffix:
Gender:F
Credentials:RN, BSN, MSN, AGPCNP
Other - Prefix:
Other - First Name:OLUWADAMILOLA
Other - Middle Name:A
Other - Last Name:ADEYEMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN, MSN, AGPCNP
Mailing Address - Street 1:303 PARKWAY DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1212
Mailing Address - Country:US
Mailing Address - Phone:912-659-0660
Mailing Address - Fax:
Practice Address - Street 1:303 PARKWAY DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:912-659-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201775363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP01292131OtherRAILROAD MEDICARE
GA003144314AMedicaid
SCNP2708Medicaid
SCNP2708Medicaid