Provider Demographics
NPI:1710581863
Name:OYEKANMI, IDARA (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:IDARA
Middle Name:
Last Name:OYEKANMI
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22281 US HIGHWAY 72 STE A
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-2601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22281 US HWY 72 WEST
Practice Address - Street 2:SUITE A
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-2601
Practice Address - Country:US
Practice Address - Phone:256-444-4401
Practice Address - Fax:256-444-4403
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-138879363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care