Provider Demographics
NPI:1154964849
Name:OYELADE, OYEBOLA OMOFADEKE
Entity type:Individual
Prefix:
First Name:OYEBOLA
Middle Name:OMOFADEKE
Last Name:OYELADE
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 1:2311 MUSTANG DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-1010
Mailing Address - Country:US
Mailing Address - Phone:281-818-0667
Mailing Address - Fax:
Practice Address - Street 1:5201 GREAT AMERICA PKWY STE 320
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-1140
Practice Address - Country:US
Practice Address - Phone:281-818-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61145520363LP0808X
TX1019705363LP0808X
CA95012789363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health