Provider Demographics
NPI:1396462016
Name:OLUMIDE, OVIGWE MODUPE I (DNP)
Entity type:Individual
Prefix:
First Name:OVIGWE
Middle Name:MODUPE
Last Name:OLUMIDE
Suffix:I
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 CROSSING CIR
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-6124
Mailing Address - Country:US
Mailing Address - Phone:912-657-6618
Mailing Address - Fax:
Practice Address - Street 1:123 CROSSING CIR
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-6124
Practice Address - Country:US
Practice Address - Phone:912-657-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA284548163W00000X
GAF03250625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse