Provider Demographics
NPI:1477806461
Name:DADA, OLASUMBO OLUWAKEMI
Entity type:Individual
Prefix:
First Name:OLASUMBO
Middle Name:OLUWAKEMI
Last Name:DADA
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 1:30 MEADOW VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4393
Mailing Address - Country:US
Mailing Address - Phone:719-231-9213
Mailing Address - Fax:
Practice Address - Street 1:MACH
Practice Address - Street 2:6600 VAN AALST BLVD
Practice Address - City:FT. MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:719-231-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN186907363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health