Provider Demographics
NPI:1558668590
Name:FASHANU, ADEDAYO
Entity Type:Individual
Prefix:MISS
First Name:ADEDAYO
Middle Name:
Last Name:FASHANU
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 1:2202 SW B AVE
Mailing Address - Street 2:APT 1309
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-4113
Mailing Address - Country:US
Mailing Address - Phone:580-458-1965
Mailing Address - Fax:
Practice Address - Street 1:807 SW F AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4506
Practice Address - Country:US
Practice Address - Phone:580-595-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731545165Medicaid