Provider Demographics
NPI:1568001840
Name:OLUSANYA, ALFRED
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:OLUSANYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 ABBEY LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-8755
Mailing Address - Country:US
Mailing Address - Phone:773-615-5475
Mailing Address - Fax:
Practice Address - Street 1:737 ABBEY LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-8755
Practice Address - Country:US
Practice Address - Phone:773-615-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336989164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse