Provider Demographics
NPI:1033595566
Name:OTUBAGA, OMOLOLA (NP)
Entity Type:Individual
Prefix:
First Name:OMOLOLA
Middle Name:
Last Name:OTUBAGA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5465 HIGHWAY 42
Mailing Address - Street 2:246
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3928
Mailing Address - Country:US
Mailing Address - Phone:470-646-3738
Mailing Address - Fax:888-910-6463
Practice Address - Street 1:101 BECKETT LN
Practice Address - Street 2:STE. 304
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7155
Practice Address - Country:US
Practice Address - Phone:770-703-4448
Practice Address - Fax:770-703-4038
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN207871363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health