Provider Demographics
NPI:1780187138
Name:OLAYIWOLE, BOLANLE BASIRAT (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:BOLANLE
Middle Name:BASIRAT
Last Name:OLAYIWOLE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 S LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-4531
Mailing Address - Country:US
Mailing Address - Phone:214-371-6639
Mailing Address - Fax:
Practice Address - Street 1:3330 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-4531
Practice Address - Country:US
Practice Address - Phone:214-743-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136921363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty