Provider Demographics
NPI:1497339220
Name:OMOLE, OLUWASEUN (APRN)
Entity Type:Individual
Prefix:
First Name:OLUWASEUN
Middle Name:
Last Name:OMOLE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 E CHANDLER BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-5117
Mailing Address - Country:US
Mailing Address - Phone:623-335-2390
Mailing Address - Fax:
Practice Address - Street 1:1915 E CHANDLER BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-5117
Practice Address - Country:US
Practice Address - Phone:623-335-2390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN183690163W00000X
AZ272897363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse