Healthcare Provider Details

I. General information

NPI: 1750254942
Provider Name (Legal Business Name): OLUSHINA O OLUTOSIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 DORCHESTER DR
PLANO TX
75075-6443
US

IV. Provider business mailing address

1645 DORCHESTER DR
PLANO TX
75075-6443
US

V. Phone/Fax

Practice location:
  • Phone: 972-777-6656
  • Fax:
Mailing address:
  • Phone: 972-777-6656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1212476
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1212476
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number1212476
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number1212476
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: