Provider Demographics
NPI:1235617267
Name:FATOBA, OLUGBENGA DANIEL (RN)
Entity Type:Individual
Prefix:
First Name:OLUGBENGA
Middle Name:DANIEL
Last Name:FATOBA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6415 PINEWOOD HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-5181
Mailing Address - Country:US
Mailing Address - Phone:929-332-3473
Mailing Address - Fax:
Practice Address - Street 1:2170 BUCKTHORNE PL STE 420
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-1794
Practice Address - Country:US
Practice Address - Phone:832-458-3793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX941683163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty