Provider Demographics
NPI:1093513236
Name:ADESUYI, OLUBOLA TOMILOLA
Entity type:Individual
Prefix:
First Name:OLUBOLA
Middle Name:TOMILOLA
Last Name:ADESUYI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12751 FAIR LAKES CIRCLE APT 403
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:509-339-4456
Mailing Address - Fax:
Practice Address - Street 1:12751 FAIR LAKES CIR APT 403
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-4953
Practice Address - Country:US
Practice Address - Phone:703-776-3491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24192768363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty