Healthcare Provider Details

I. General information

NPI: 1720909112
Provider Name (Legal Business Name): MR. TOBI AYOOLUUWA KOLAWOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5236 W PEORIA AVE APT 143
GLENDALE AZ
85302-1624
US

IV. Provider business mailing address

5236 W PEORIA AVE APT 143
GLENDALE AZ
85302-1624
US

V. Phone/Fax

Practice location:
  • Phone: 602-736-4126
  • Fax:
Mailing address:
  • Phone: 602-736-4126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number269514
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: