Provider Demographics
NPI:1760957070
Name:OMOTOSHO, TOYIN KIKELOMO (RN)
Entity Type:Individual
Prefix:MRS
First Name:TOYIN
Middle Name:KIKELOMO
Last Name:OMOTOSHO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:TOYIN
Other - Middle Name:KIKELOMO
Other - Last Name:OMOTOSHO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:TOYIN OMOTOSHO
Mailing Address - Street 1:2908 MONTALBO
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6506
Mailing Address - Country:US
Mailing Address - Phone:972-352-9449
Mailing Address - Fax:
Practice Address - Street 1:2908 MONTALBO
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-6506
Practice Address - Country:US
Practice Address - Phone:972-352-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23316098Medicaid