Provider Demographics
NPI:1417623984
Name:ABDUL, OMOTAYO OMOSEBI (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:OMOSEBI
Last Name:ABDUL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TAYO
Other - Middle Name:O
Other - Last Name:ABDUL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7772 THRAILKILL RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2459
Mailing Address - Country:US
Mailing Address - Phone:404-567-3262
Mailing Address - Fax:
Practice Address - Street 1:7772 THRAILKILL RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2459
Practice Address - Country:US
Practice Address - Phone:404-567-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1146032084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty