Provider Demographics
NPI:1447635461
Name:OMIDELE, OLUWAFISHAYO OMOKEHINDE (NP-C)
Entity type:Individual
Prefix:
First Name:OLUWAFISHAYO
Middle Name:OMOKEHINDE
Last Name:OMIDELE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-2704
Mailing Address - Fax:281-732-0439
Practice Address - Street 1:18220 STATE HIGHWAY 249 STE 130
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4371
Practice Address - Country:US
Practice Address - Phone:281-737-0435
Practice Address - Fax:281-737-0439
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCNP500007162363L00000X
TX779886363LA2200X
TXAP128397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health