Provider Demographics
NPI:1063014496
Name:AWODU, OLUSOLA (RN)
Entity Type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:
Last Name:AWODU
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N MAIN ST STE C2ND
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-6700
Mailing Address - Country:US
Mailing Address - Phone:857-247-0263
Mailing Address - Fax:
Practice Address - Street 1:500 N MAIN ST STE C2ND
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-6700
Practice Address - Country:US
Practice Address - Phone:857-247-0263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2297551163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health