Healthcare Provider Details

I. General information

NPI: 1861091191
Provider Name (Legal Business Name): TAJUDEEN ADEBAYO KOLAWOLE MBBS, MPH, CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD STE 407
CHESTER PA
19013-3902
US

IV. Provider business mailing address

1 MEDICAL CENTER BLVD STE 407
CHESTER PA
19013-3902
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-7413
  • Fax: 610-874-7241
Mailing address:
  • Phone: 610-619-7413
  • Fax: 610-874-7241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP022671
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: