Provider Demographics
NPI:1508532227
Name:AGBOOLA, OLUSOLA TESSY
Entity Type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:TESSY
Last Name:AGBOOLA
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 1:32923 SILVER MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-2885
Mailing Address - Country:US
Mailing Address - Phone:763-291-3647
Mailing Address - Fax:
Practice Address - Street 1:26265 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-1760
Practice Address - Country:US
Practice Address - Phone:281-758-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-22
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1035548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily