Provider Demographics
NPI:1235634635
Name:OLATOTO, OLUBUKOLA FUNMI (NP)
Entity Type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:FUNMI
Last Name:OLATOTO
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 1:6609 WATERTON AVE SW # 6609
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-9447
Mailing Address - Country:US
Mailing Address - Phone:770-905-3163
Mailing Address - Fax:
Practice Address - Street 1:445 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030
Practice Address - Country:US
Practice Address - Phone:404-508-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA201190363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health