Provider Demographics
NPI:1992409544
Name:BALOGUN, ABIBAT (WENDY) YEWANDE
Entity type:Individual
Prefix:
First Name:ABIBAT (WENDY)
Middle Name:YEWANDE
Last Name:BALOGUN
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 1:1121 JOHNSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-5425
Mailing Address - Country:US
Mailing Address - Phone:770-694-6349
Mailing Address - Fax:
Practice Address - Street 1:1121 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5425
Practice Address - Country:US
Practice Address - Phone:770-694-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN194681363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health