Provider Demographics
NPI:1376994566
Name:ODUTAYO, OLASIMBO IFASEWA
Entity Type:Individual
Prefix:MRS
First Name:OLASIMBO
Middle Name:IFASEWA
Last Name:ODUTAYO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:OLASIMBO
Other - Middle Name:IFASEWA
Other - Last Name:ODUTAYO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:308 AUTUMN PARK
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-6524
Mailing Address - Country:US
Mailing Address - Phone:682-552-3574
Mailing Address - Fax:
Practice Address - Street 1:308 AUTUMN PARK
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-6524
Practice Address - Country:US
Practice Address - Phone:682-552-3574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily