Healthcare Provider Details

I. General information

NPI: 1669953071
Provider Name (Legal Business Name): OLUBUNMI OLAIDE OLAWALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MAYOR THOMAS J MCGRATH HWY STE 306
QUINCY MA
02169-5351
US

IV. Provider business mailing address

21 MAYOR THOMAS J MCGRATH HWY STE 306
QUINCY MA
02169-5351
US

V. Phone/Fax

Practice location:
  • Phone: 781-742-0834
  • Fax: 781-459-2666
Mailing address:
  • Phone: 781-742-0834
  • Fax: 781-459-2666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN2264640
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2264640
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: