Provider Demographics
NPI:1700587961
Name:OGUNNIYI, LOLA (PMHNP)
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:OGUNNIYI
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 FIVE FORKS TRICKUM RD SW STE D454
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1810
Mailing Address - Country:US
Mailing Address - Phone:470-871-9105
Mailing Address - Fax:
Practice Address - Street 1:1841 MONTREAL RD STE 111
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5712
Practice Address - Country:US
Practice Address - Phone:404-725-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN307055363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health