Healthcare Provider Details

I. General information

NPI: 1548699739
Provider Name (Legal Business Name): OMOTOLU OLAITAN AJE-OMOKORE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 N WEST ST, WICHITA, KS 67203
WICHITA KS
67226
US

IV. Provider business mailing address

2801 N ROCK RD APT 1508
WICHITA KS
67226-1185
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-5691
  • Fax:
Mailing address:
  • Phone: 316-990-4126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number53-76179-091
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60590699
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: