MEDICARE: SHOLA ADEWUNMI PMHNP

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	AC002778	MD
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP61063594	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AP61063594	OTHER	WA	WA ST. DEPT. OF HEALTH
2	RN61063515	OTHER	WA	WA. ST. DEPT. OF HEALTH

General Provider Information

NPI Number	:	1073168449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHOLA ADEWUNMI PMHNP

Provider Business Mailing Address
First Line	:	1515 E COLUMBIA ST
Second Line	:
City	:	OTHELLO
State	:	WA
Zip	:	99344-1846
Country	:	US
Telephone Number	:	509-488-5256
Fax Number	:	509-488-9939

Provider Business Practice Location Address
First Line	:	6115 BURDEN BLVD STE D
Second Line	:
City	:	PASCO
State	:	WA
Zip	:	99301-0010
Country	:	US
Telephone Number	:	509-488-5256
Fax Number	:	509-488-9939

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

Provider Enumeration Date	:	08/02/2019
Last Update Date	:	01/29/2024

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