Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT012084 | GA |
NPI | 1003282526 |
---|---|
Provider Name | Dr. Moronke Ogundele |
First Address | Jonesboro, GA 30236-1071 |
Second Address | Jonesboro, GA 30236-1071 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2015 |
Last Update Date | 06/08/2020 |