Healthcare Provider Details

I. General information

NPI: 1689134413
Provider Name (Legal Business Name): FIDELIA OLABODE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W SEMANDS ST
CONROE TX
77301-1867
US

IV. Provider business mailing address

12710 BRANT ROCK DR APT 1105
HOUSTON TX
77082-5433
US

V. Phone/Fax

Practice location:
  • Phone: 781-486-4116
  • Fax:
Mailing address:
  • Phone: 832-279-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number960266
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: