Provider Demographics
NPI:1386073914
Name:OLUMEGBON, BISOLA
Entity type:Individual
Prefix:
First Name:BISOLA
Middle Name:
Last Name:OLUMEGBON
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 1:7914 ROYAL LN APT A
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-3733
Mailing Address - Country:US
Mailing Address - Phone:469-443-2830
Mailing Address - Fax:214-339-7326
Practice Address - Street 1:4373 S HAMPTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-1058
Practice Address - Country:US
Practice Address - Phone:214-339-9359
Practice Address - Fax:214-339-7326
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX675610363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF06131088OtherAANP
TX675610OtherBOARD OF NURSING EXAMINERS