Provider Demographics
NPI:1003490764
Name:OSADIAYE, GLORY (PMHNP, MSN, BSN, RN)
Entity type:Individual
Prefix:
First Name:GLORY
Middle Name:
Last Name:OSADIAYE
Suffix:
Gender:F
Credentials:PMHNP, MSN, BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CONSTITUTION BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8432
Mailing Address - Country:US
Mailing Address - Phone:470-844-0157
Mailing Address - Fax:
Practice Address - Street 1:250 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8432
Practice Address - Country:US
Practice Address - Phone:470-844-0157
Practice Address - Fax:678-539-8899
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN250999163W00000X, 163WH0200X, 163WH1000X, 163WM0705X, 163WP0808X, 363LP0808X
GA250999363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health