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General NPI Number Information
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NPI Number | 1598395725
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Entity Type | Individual
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Provider Name | AYODEJI BAMIDELE OLAWALE PMHNP
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Gender | Male
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Dates
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Enumeration Date | 01/15/2020
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 80 SEYMOUR ST
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City | HARTFORD
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State | CT
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Zip | 06102-8000
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Country | US
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Telephone | 860-972-2629
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Fax |
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Provider Business Mailing Address
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Address Line | 11715 BASSWOOD DR
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City | LAUREL
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State | MD
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Zip | 20708-3167
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Country | US
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Telephone | 301-905-2947
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Fax |
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | R210564
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 10362
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License Number State | CT
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