Provider Demographics
NPI:1508424029
Name:OBASOLUYI, SHELLY RENEA
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RENEA
Last Name:OBASOLUYI
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 1:403 ATWELL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0122
Mailing Address - Country:US
Mailing Address - Phone:910-260-8842
Mailing Address - Fax:
Practice Address - Street 1:403 ATWELL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-0122
Practice Address - Country:US
Practice Address - Phone:910-260-8842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty