Provider Demographics
NPI:1942938816
Name:KOMOLAFE, TITILOPE J
Entity Type:Individual
Prefix:
First Name:TITILOPE
Middle Name:J
Last Name:KOMOLAFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 CYPRESS GLEN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:817-606-7547
Mailing Address - Fax:
Practice Address - Street 1:2828 CYPRESS GLEN DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052
Practice Address - Country:US
Practice Address - Phone:817-606-7547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1089282363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health