Provider Demographics
NPI:1962783639
Name:GADDIS, FUNLOLA M (NP-C)
Entity type:Individual
Prefix:MRS
First Name:FUNLOLA
Middle Name:M
Last Name:GADDIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:FUNLOLA
Other - Middle Name:M
Other - Last Name:AWOYEMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1365 ROCK QUARRY RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5029
Mailing Address - Country:US
Mailing Address - Phone:770-771-6580
Mailing Address - Fax:
Practice Address - Street 1:1365 ROCK QUARRY RD
Practice Address - Street 2:SUITE 301
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5029
Practice Address - Country:US
Practice Address - Phone:770-771-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN186624363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily