MEDICARE: OMOLOLA ADETUNJI

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	363LG0600X	Gerontology Nurse Practitioner	AP135359	TX

General Provider Information

NPI Number	:	1619485893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMOLOLA ADETUNJI

Provider Business Mailing Address
First Line	:	3826 CARTERS LAKE DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-6970
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3826 CARTERS LAKE DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-6970
Country	:	US
Telephone Number	:	832-878-1823
Fax Number	:

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

Provider Enumeration Date	:	01/22/2018
Last Update Date	:	01/22/2018

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Directions to “ OMOLOLA ADETUNJI ” Practice Location

Language	Start Address	Practice Location

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