Provider Demographics
NPI:1578532065
Name:FYLE THORPE, OMOLARA
Entity Type:Individual
Prefix:
First Name:OMOLARA
Middle Name:
Last Name:FYLE THORPE
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 1:6873 CULPEPER CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5210
Mailing Address - Country:US
Mailing Address - Phone:314-653-0011
Mailing Address - Fax:
Practice Address - Street 1:6873 CULPEPER CT
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5210
Practice Address - Country:US
Practice Address - Phone:314-653-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07836363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2490684Medicaid
OHFYNP15761Medicare ID - Type Unspecified
OH2490684Medicaid