Provider Demographics
NPI:1285283176
Name:NA-ALLAH, MORIAM BOLARE
Entity type:Individual
Prefix:DR
First Name:MORIAM
Middle Name:BOLARE
Last Name:NA-ALLAH
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 1:2712 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6531
Mailing Address - Country:US
Mailing Address - Phone:405-923-0952
Mailing Address - Fax:
Practice Address - Street 1:2712 GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-6531
Practice Address - Country:US
Practice Address - Phone:405-923-0952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK111165363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK111165OtherOKLAHOMA BOARD OF NURSING