Provider Demographics
NPI:1982339719
Name:GANDONU, OLUBUSOLA (AGNP-C)
Entity Type:Individual
Prefix:
First Name:OLUBUSOLA
Middle Name:
Last Name:GANDONU
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 BUFORD HWY
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2654
Mailing Address - Country:US
Mailing Address - Phone:678-445-5995
Mailing Address - Fax:844-270-4279
Practice Address - Street 1:5245 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30071-2654
Practice Address - Country:US
Practice Address - Phone:678-445-5995
Practice Address - Fax:844-270-4279
Is Sole Proprietor?:No
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA232352163W00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse