Provider Demographics
NPI:1508482746
Name:AYENI, OLUBUNMI TINA (NP)
Entity Type:Individual
Prefix:MRS
First Name:OLUBUNMI
Middle Name:TINA
Last Name:AYENI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:OLUBUNMI
Other - Middle Name:ADIJAT KUBURAT
Other - Last Name:SONUGA
Other - Suffix:
Other - Last Name Type:Former Name
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:770-603-0515
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:770-603-0515
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174210363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN174210OtherADVANCED PRACTICE LICENSE