Provider Demographics
NPI:1790358976
Name:BAMIDELE, OLUWABUNMI M (APN)
Entity Type:Individual
Prefix:
First Name:OLUWABUNMI
Middle Name:M
Last Name:BAMIDELE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 NORWICH CT
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-1499
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 NORWICH CT
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-1499
Practice Address - Country:US
Practice Address - Phone:615-738-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000028533363L00000X
TNRN0000195960163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110732571OtherDRIVER'S LICENSE