Provider Demographics
NPI:1750033684
Name:AJALA, OLUFUNMILAYO TEMITOPE
Entity Type:Individual
Prefix:
First Name:OLUFUNMILAYO
Middle Name:TEMITOPE
Last Name:AJALA
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 1:2121 FOUNTAIN DR STE D
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2900
Mailing Address - Country:US
Mailing Address - Phone:470-435-5341
Mailing Address - Fax:
Practice Address - Street 1:2121 FOUNTAIN DR STE D
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2900
Practice Address - Country:US
Practice Address - Phone:470-435-5341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222212163WM0705X, 363LP0808X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice