Provider Demographics
NPI:1225379050
Name:ADELEYE, OLAMIDE O (NP)
Entity Type:Individual
Prefix:
First Name:OLAMIDE
Middle Name:O
Last Name:ADELEYE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0005
Mailing Address - Country:US
Mailing Address - Phone:662-536-1892
Mailing Address - Fax:662-536-1859
Practice Address - Street 1:1890 GOODMAN RD E
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9504
Practice Address - Country:US
Practice Address - Phone:662-536-1892
Practice Address - Fax:662-536-1859
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17031363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner