Provider Demographics
NPI:1801577820
Name:KOLAWOLE, OLAMIDE T
Entity type:Individual
Prefix:
First Name:OLAMIDE
Middle Name:T
Last Name:KOLAWOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLAMIDE
Other - Middle Name:T
Other - Last Name:ISRAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2636 WALNUT HILL LN STE 350
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-5684
Mailing Address - Country:US
Mailing Address - Phone:469-432-7154
Mailing Address - Fax:
Practice Address - Street 1:2636 WALNUT HILL LN STE 350
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-5684
Practice Address - Country:US
Practice Address - Phone:469-432-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2023086798363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty