Provider Demographics
NPI:1760206130
Name:OLUWAFERANMI, OLUBUSOLA F (LMT)
Entity type:Individual
Prefix:
First Name:OLUBUSOLA
Middle Name:F
Last Name:OLUWAFERANMI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 CHANDLER BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-4320
Mailing Address - Country:US
Mailing Address - Phone:678-906-7881
Mailing Address - Fax:
Practice Address - Street 1:455 GRAYSON HWY STE 114C
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7159
Practice Address - Country:US
Practice Address - Phone:678-564-4518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT015144225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist