MEDICARE: ADESOLA W OLUTAYO APRN- 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	1194437	TX

General Provider Information

NPI Number	:	1790570430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADESOLA W OLUTAYO APRN- PMHNP

Provider Business Mailing Address
First Line	:	3831 TARRAGON BEND DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-2618
Country	:	US
Telephone Number	:	713-478-2758
Fax Number	:	281-318-1890

Provider Business Practice Location Address
First Line	:	3831 TARRAGON BEND DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-2618
Country	:	US
Telephone Number	:	713-478-2758
Fax Number	:	281-318-1890

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

Provider Enumeration Date	:	04/14/2025
Last Update Date	:	04/14/2025

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