Provider Demographics
NPI:1699476796
Name:OLOTU, OLUBUKOLA
Entity type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:
Last Name:OLOTU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1784 BROOKSTONE CT NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4562
Mailing Address - Country:US
Mailing Address - Phone:872-212-7240
Mailing Address - Fax:
Practice Address - Street 1:1784 BROOKSTONE CT NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4562
Practice Address - Country:US
Practice Address - Phone:872-212-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9627720163W00000X
GALPN100801164W00000X
IL043.131119164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse