Provider Demographics
NPI:1164135570
Name:OWOLABI, ADETUTU (CNP)
Entity Type:Individual
Prefix:
First Name:ADETUTU
Middle Name:
Last Name:OWOLABI
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 PARAGON RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-5127
Mailing Address - Country:US
Mailing Address - Phone:617-755-1653
Mailing Address - Fax:
Practice Address - Street 1:200 MAY ST
Practice Address - Street 2:
Practice Address - City:SOUTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-5520
Practice Address - Country:US
Practice Address - Phone:508-761-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-30
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309251163WP0807X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent