Provider Demographics
NPI:1003561705
Name:FANUSI, OLUFEMI OLAWALE
Entity Type:Individual
Prefix:MR
First Name:OLUFEMI
Middle Name:OLAWALE
Last Name:FANUSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 KENSINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:STONECREST
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3239
Mailing Address - Country:US
Mailing Address - Phone:678-680-9209
Mailing Address - Fax:
Practice Address - Street 1:4202 KENSINGTON CIR
Practice Address - Street 2:
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30038-3239
Practice Address - Country:US
Practice Address - Phone:678-680-9209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN285470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily