Provider Demographics
NPI:1457607129
Name:FADAYOMI, ABIOLA (NP)
Entity Type:Individual
Prefix:MRS
First Name:ABIOLA
Middle Name:
Last Name:FADAYOMI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:OSUOLALE
Other - Middle Name:ABIOLA
Other - Last Name:AYORINDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-0624
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-8600
Practice Address - Fax:214-645-8601
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2017-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126155363L00000X
CA22131363LG0600X
TX848632363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology