Provider Demographics
NPI:1295394450
Name:OLAYEMI, OLANREWAJU PETER
Entity Type:Individual
Prefix:
First Name:OLANREWAJU
Middle Name:PETER
Last Name:OLAYEMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 MINECREEK CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2274
Mailing Address - Country:US
Mailing Address - Phone:214-284-5501
Mailing Address - Fax:
Practice Address - Street 1:706 MINECREEK CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2274
Practice Address - Country:US
Practice Address - Phone:214-284-5501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30380363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty