Provider Demographics
NPI:1114212115
Name:OLAWUYI, TIWALADE (NP)
Entity Type:Individual
Prefix:
First Name:TIWALADE
Middle Name:
Last Name:OLAWUYI
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 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7366
Mailing Address - Fax:502-568-7114
Practice Address - Street 1:811 KENNESAW AVE NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1002
Practice Address - Country:US
Practice Address - Phone:770-422-2451
Practice Address - Fax:770-499-8460
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN193864NP363LF0000X
GA193864363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN193864OtherRN
GARN193864NPOtherNP LICENSE
GA003110136BMedicaid
GA202I503003Medicare PIN