Basic Information
| Provider Information | |||||||||
| NPI: | 1831693357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODEDE | ||||||||
| FirstName: | BAMIDELE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 VALLEY CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LITHIA SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301223647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435278356 | ||||||||
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| Practice Location | |||||||||
| Address1: | 445 WINN WAY | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042943835 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 5010392 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0809X | RN213970 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
No ID Information.