Provider Demographics
NPI:1386463651
Name:OLAOYE, IBUKUNOLUWA
Entity type:Individual
Prefix:
First Name:IBUKUNOLUWA
Middle Name:
Last Name:OLAOYE
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 1:159 MELROSE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-2351
Mailing Address - Country:US
Mailing Address - Phone:678-571-4455
Mailing Address - Fax:
Practice Address - Street 1:400 TOWER RD NE STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9412
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA12685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant