Healthcare Provider Details

I. General information

NPI: 1205211802
Provider Name (Legal Business Name): ANTHONY VINCENT OLORUNSOLA PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 01/16/2023
Certification Date: 01/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 S LAKESHORE DR
TEMPE AZ
85282-8339
US

IV. Provider business mailing address

11211 E SONRISA AVE
MESA AZ
85212-7079
US

V. Phone/Fax

Practice location:
  • Phone: 623-806-6864
  • Fax:
Mailing address:
  • Phone: 623-806-6864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP7477
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP7477
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: