Healthcare Provider Details

I. General information

NPI: 1952034191
Provider Name (Legal Business Name): OLULEKE ANTHONY OLAIYA PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 W ELM ST
ROGERS AR
72758-4018
US

IV. Provider business mailing address

3600 S NATIONAL AVE
SPRINGFIELD MO
65807-7311
US

V. Phone/Fax

Practice location:
  • Phone: 479-427-7722
  • Fax: 479-427-7721
Mailing address:
  • Phone: 417-322-6622
  • Fax: 417-350-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number223594
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: