Provider Demographics
NPI:1588148365
Name:AWOTIKU, BOLANLE (NP)
Entity type:Individual
Prefix:
First Name:BOLANLE
Middle Name:
Last Name:AWOTIKU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11747 GIOVANNI LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1536
Mailing Address - Country:US
Mailing Address - Phone:630-504-8745
Mailing Address - Fax:
Practice Address - Street 1:11747 GIOVANNI LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-1536
Practice Address - Country:US
Practice Address - Phone:630-504-8745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2024-01-22
Deactivation Date:2023-12-17
Deactivation Code:
Reactivation Date:2024-01-16
Provider Licenses
StateLicense IDTaxonomies
TX1124240363LP0808X
TX950536163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health