Provider Demographics
NPI:1205327764
Name:OLAWALE, OLUSOLA CARLTON
Entity type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:CARLTON
Last Name:OLAWALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 THORN RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6129
Mailing Address - Country:US
Mailing Address - Phone:614-599-3617
Mailing Address - Fax:877-779-5837
Practice Address - Street 1:1684 THORN RIDGE TRL
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228
Practice Address - Country:US
Practice Address - Phone:614-599-3617
Practice Address - Fax:877-779-5837
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201539363LP0808X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty