Healthcare Provider Details

I. General information

NPI: 1932951522
Provider Name (Legal Business Name): MRS. ADESOLA OMOWANILE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10223 BROADWAY ST
PEARLAND TX
77584-7880
US

IV. Provider business mailing address

29030 DUNBROOK MEADOWS LN
KATY TX
77494-3820
US

V. Phone/Fax

Practice location:
  • Phone: 646-541-1016
  • Fax:
Mailing address:
  • Phone: 646-541-1016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number224137
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1154274
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number948801
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: