Provider Demographics
NPI:1710483615
Name:AYEDUN, OLABISI OMOWUMI (LVN)
Entity Type:Individual
Prefix:
First Name:OLABISI
Middle Name:OMOWUMI
Last Name:AYEDUN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 AUTUMN RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-3808
Mailing Address - Country:US
Mailing Address - Phone:972-704-4209
Mailing Address - Fax:
Practice Address - Street 1:1349 EMPIRE CENTRAL DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4066
Practice Address - Country:US
Practice Address - Phone:469-364-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2018-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228251164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty