Provider Demographics
NPI:1508422296
Name:OMORODION, ADESUWA TAIYE
Entity Type:Individual
Prefix:
First Name:ADESUWA
Middle Name:TAIYE
Last Name:OMORODION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 S FORUM DR APT 17201
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7049
Mailing Address - Country:US
Mailing Address - Phone:817-673-6067
Mailing Address - Fax:
Practice Address - Street 1:2650 S FORUM DR APT 17201
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7049
Practice Address - Country:US
Practice Address - Phone:817-673-6067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302634164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse