Provider Demographics
NPI:1689124125
Name:ADELEKAN-ADEOGUN, LATIFAT
Entity Type:Individual
Prefix:
First Name:LATIFAT
Middle Name:
Last Name:ADELEKAN-ADEOGUN
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 1:404 E BROAD ST STE 600
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-1743
Mailing Address - Country:US
Mailing Address - Phone:319-600-6693
Mailing Address - Fax:
Practice Address - Street 1:404 E BROAD ST STE 600
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1743
Practice Address - Country:US
Practice Address - Phone:319-600-6693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132188363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health