Provider Demographics
NPI:1346940996
Name:OLEMUSA, WINNIE KENYANYA
Entity Type:Individual
Prefix:
First Name:WINNIE
Middle Name:KENYANYA
Last Name:OLEMUSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2759 MOUNT ZION PKWY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2568
Mailing Address - Country:US
Mailing Address - Phone:678-289-8338
Mailing Address - Fax:
Practice Address - Street 1:2759 MOUNT ZION PKWY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2568
Practice Address - Country:US
Practice Address - Phone:678-289-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN253327163W00000X
GAF06212497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse