Provider Demographics
NPI:1578215091
Name:OLAGBAMI, OLUSOLA
Entity Type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:
Last Name:OLAGBAMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLUSOLA
Other - Middle Name:
Other - Last Name:OLAGBAMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1053 MEADOW SCAPE DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-1885
Mailing Address - Country:US
Mailing Address - Phone:682-472-4968
Mailing Address - Fax:
Practice Address - Street 1:1053 MEADOW SCAPE DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-1885
Practice Address - Country:US
Practice Address - Phone:682-472-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1057391363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health