=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578215091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLUSOLA OLAGBAMI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2022
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1053 MEADOW SCAPE DR
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-1885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-472-4968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1053 MEADOW SCAPE DR
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-1885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-472-4968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 1057391
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------