Provider Demographics
NPI:1639766199
Name:OLUDE, FADEKEMI SULIAT (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:FADEKEMI
Middle Name:SULIAT
Last Name:OLUDE
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 AVA DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-2274
Mailing Address - Country:US
Mailing Address - Phone:713-291-8625
Mailing Address - Fax:
Practice Address - Street 1:444 E BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3708
Practice Address - Country:US
Practice Address - Phone:713-291-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1023087363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty