Provider Demographics
NPI:1689134413
Name:OLABODE, FIDELIA
Entity Type:Individual
Prefix:
First Name:FIDELIA
Middle Name:
Last Name:OLABODE
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 1:12710 BRANT ROCK DR APT 1105
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-5433
Mailing Address - Country:US
Mailing Address - Phone:832-279-3568
Mailing Address - Fax:
Practice Address - Street 1:602 W SEMANDS ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1867
Practice Address - Country:US
Practice Address - Phone:781-486-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX960266163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0301OtherMINE