Provider Demographics
NPI:1649493537
Name:ADEGBUJI, OMORONKE (FNP-C)
Entity type:Individual
Prefix:
First Name:OMORONKE
Middle Name:
Last Name:ADEGBUJI
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 N POINT PKWY
Mailing Address - Street 2:ATTN CREDENTIALING DEPT, BUILDING F, SUITE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:770-645-8455
Practice Address - Street 1:1000 JOHNSON FERRY ROAD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:770-645-9181
Practice Address - Fax:770-645-8455
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN161489363L00000X
GARN161498363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA486548249AMedicaid