Healthcare Provider Details

I. General information

NPI: 1164135570
Provider Name (Legal Business Name): ADETUTU OWOLABI CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAY ST
SOUTH ATTLEBORO MA
02703-5520
US

IV. Provider business mailing address

59 PARAGON RD
WEST ROXBURY MA
02132-5127
US

V. Phone/Fax

Practice location:
  • Phone: 508-761-8500
  • Fax:
Mailing address:
  • Phone: 617-755-1653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN2309251
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2309251
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: