Provider Demographics
NPI:1598300402
Name:PETERS, OLUDOTUN OLUYEMI (PMHNP)
Entity Type:Individual
Prefix:
First Name:OLUDOTUN
Middle Name:OLUYEMI
Last Name:PETERS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:901 7TH AVE STE 2200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2722
Practice Address - Country:US
Practice Address - Phone:682-885-1050
Practice Address - Fax:682-885-7572
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143490363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX404348101Medicaid