Provider Demographics
NPI:1528703097
Name:OLUSANYA, ABIDEMI (PSYCH-NP)
Entity type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:
Last Name:OLUSANYA
Suffix:
Gender:F
Credentials:PSYCH-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 COLE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-1083
Mailing Address - Country:US
Mailing Address - Phone:469-613-2110
Mailing Address - Fax:469-809-7865
Practice Address - Street 1:2626 COLE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-1083
Practice Address - Country:US
Practice Address - Phone:469-613-2110
Practice Address - Fax:469-809-7865
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1062198363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health