MEDICARE: OMOLARA ABIDEMI OLANREWAJU

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	163W00000X	Registered Nurse	734757	TX
2	363LF0000X	Family Nurse Practitioner	F06190014	TX

General Provider Information

NPI Number	:	1306426549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMOLARA ABIDEMI OLANREWAJU

Provider Business Mailing Address
First Line	:	2535 E ARKANSAS LN STE 311
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-8702
Country	:	US
Telephone Number	:	817-874-6387
Fax Number	:

Provider Business Practice Location Address
First Line	:	2535 E ARKANSAS LN STE 311
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-8702
Country	:	US
Telephone Number	:	817-874-6387
Fax Number	:

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

Provider Enumeration Date	:	04/12/2021
Last Update Date	:	04/22/2021

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