Healthcare Provider Details

I. General information

NPI: 1174345425
Provider Name (Legal Business Name): OLUKEMI MOTUNRAYO OLOGUN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 OLD HICKORY TRL
DESOTO TX
75115-2242
US

IV. Provider business mailing address

2000 OLD HICKORY TRL
DESOTO TX
75115-2242
US

V. Phone/Fax

Practice location:
  • Phone: 972-298-7323
  • Fax:
Mailing address:
  • Phone: 972-298-7323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number1104601
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: