Provider Demographics
NPI:1477189157
Name:AGBOJEYIN, FATIMAT OLUMAYOWA OLUFUNMILAYO
Entity Type:Individual
Prefix:
First Name:FATIMAT OLUMAYOWA
Middle Name:OLUFUNMILAYO
Last Name:AGBOJEYIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLUMAYOWA
Other - Middle Name:OLUFUNMILAYO
Other - Last Name:AGBOEYIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:105 EMERALD LAKE CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-7748
Mailing Address - Country:US
Mailing Address - Phone:404-513-2868
Mailing Address - Fax:
Practice Address - Street 1:105 EMERALD LAKE CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-7748
Practice Address - Country:US
Practice Address - Phone:404-513-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA177491363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12345678Medicaid