MEDICARE: OLUWATAYO ODEYEMI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver
2	163W00000X	Registered Nurse	1058973	TX

General Provider Information

NPI Number	:	1558117218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLUWATAYO ODEYEMI

Provider Business Mailing Address
First Line	:	14249 LAKE LODGE DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77384-1539
Country	:	US
Telephone Number	:	940-231-6643
Fax Number	:

Provider Business Practice Location Address
First Line	:	14249 LAKE LODGE DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77384-1539
Country	:	US
Telephone Number	:	940-231-6643
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2024
Last Update Date	:	07/19/2024

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Directions to “ OLUWATAYO ODEYEMI ” Practice Location

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