Provider Demographics
NPI:1376056341
Name:OMOLE, OLUWABUSAYO OLUKEMI (NP-C)
Entity Type:Individual
Prefix:
First Name:OLUWABUSAYO
Middle Name:OLUKEMI
Last Name:OMOLE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 BALTRUSOL PL
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-5904
Mailing Address - Country:US
Mailing Address - Phone:561-633-0689
Mailing Address - Fax:
Practice Address - Street 1:1668 BALTRUSOL PL
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-5904
Practice Address - Country:US
Practice Address - Phone:561-633-0689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF10170945363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner