Healthcare Provider Details

I. General information

NPI: 1063087849
Provider Name (Legal Business Name): OLAWALE NURUDEEN MOYOSORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HIGHWAY 89 NORTH
PRESCOTT AZ
86313
US

IV. Provider business mailing address

181 WHIPPLE ST
PRESCOTT AZ
86301-1705
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-4860
  • Fax:
Mailing address:
  • Phone: 480-719-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number262277
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP143491
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: