Provider Demographics
NPI:1245715903
Name:AGBEYOMI, MODUPE (DNP, FNP-C)
Entity type:Individual
Prefix:DR
First Name:MODUPE
Middle Name:
Last Name:AGBEYOMI
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CORPORATE BLVD NE STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1900
Mailing Address - Country:US
Mailing Address - Phone:770-557-1079
Mailing Address - Fax:770-872-6621
Practice Address - Street 1:13 CORPORATE BLVD NE STE 200
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-1900
Practice Address - Country:US
Practice Address - Phone:770-557-1079
Practice Address - Fax:770-872-6621
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251F00000X, 261QI0500X, 261QM1000X
GAF09180151363LP2300X, 363LS0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF09180151Medicaid