Provider Demographics
NPI:1417336249
Name:OGUNNAIKE, ABIMBOLA
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:OGUNNAIKE
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 1:1513 BROOKSTONE RD
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-8912
Mailing Address - Country:US
Mailing Address - Phone:478-456-3173
Mailing Address - Fax:
Practice Address - Street 1:3421 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-432-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN220112163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse