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General NPI Number Information
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NPI Number | 1053174540
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Entity Type | Individual
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Provider Name | ADEMOLA AKINLAYO FATADE OTA
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Gender | Male
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Dates
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Enumeration Date | 02/06/2024
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Last Update Date | 02/06/2024
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Provider Practice Location Address
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Address Line | 2910 W DESOTO ST
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City | PENSACOLA
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State | FL
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Zip | 32505-6161
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Country | US
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Telephone | 850-324-1494
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Fax | 850-782-0058
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Provider Business Mailing Address
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Address Line | PO BOX 56
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City | WATER VALLEY
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State | MS
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Zip | 38965-0056
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Country | US
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Telephone | 850-324-1494
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Fax | 850-782-0058
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 19726
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License Number State | FL
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