Provider Demographics
NPI:1841017944
Name:FAFORE, OLABISI FASHUYI
Entity type:Individual
Prefix:
First Name:OLABISI
Middle Name:FASHUYI
Last Name:FAFORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1183 LANIER SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7272
Mailing Address - Country:US
Mailing Address - Phone:612-227-4763
Mailing Address - Fax:
Practice Address - Street 1:367 RESOURCE PKWY
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8364
Practice Address - Country:US
Practice Address - Phone:612-227-4763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-21
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15240800363LP0808X
GARN297527363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health