Provider Demographics
NPI:1306426549
Name:OLANREWAJU, OMOLARA ABIDEMI
Entity type:Individual
Prefix:
First Name:OMOLARA
Middle Name:ABIDEMI
Last Name:OLANREWAJU
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 1:2535 E ARKANSAS LN STE 311
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010-8702
Mailing Address - Country:US
Mailing Address - Phone:817-874-6387
Mailing Address - Fax:
Practice Address - Street 1:2535 E ARKANSAS LN STE 311
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-8702
Practice Address - Country:US
Practice Address - Phone:817-874-6387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX734757163W00000X
TXF06190014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty