Provider Demographics
NPI:1932701984
Name:SOETAN, OLUWASEYI LADIPUPO (PMHNP - BC)
Entity Type:Individual
Prefix:
First Name:OLUWASEYI
Middle Name:LADIPUPO
Last Name:SOETAN
Suffix:
Gender:M
Credentials:PMHNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 OAKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9339
Mailing Address - Country:US
Mailing Address - Phone:540-204-2459
Mailing Address - Fax:
Practice Address - Street 1:26317 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23803-2727
Practice Address - Country:US
Practice Address - Phone:804-524-4504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180400363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health