MEDICARE: OMOLAYO FANIMO MSN, APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	115884	NE

General Provider Information

NPI Number	:	1053103689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMOLAYO FANIMO MSN, APRN

Provider Business Mailing Address
First Line	:	7340 NOLAN RD
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68512-3679
Country	:	US
Telephone Number	:	402-413-6677
Fax Number	:	402-817-0210

Provider Business Practice Location Address
First Line	:	7340 NOLAN RD
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68512-3679
Country	:	US
Telephone Number	:	714-948-0166
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2025
Last Update Date	:	02/07/2026

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