Provider Demographics
NPI:1033800503
Name:OMOTOSHO, OLAYEMI (NP)
Entity type:Individual
Prefix:
First Name:OLAYEMI
Middle Name:
Last Name:OMOTOSHO
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 1:2340 TEXAS HERITAGE PKWY STE 700
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-4637
Mailing Address - Country:US
Mailing Address - Phone:346-287-6006
Mailing Address - Fax:
Practice Address - Street 1:2340 TEXAS HERITAGE PKWY STE 700
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-4637
Practice Address - Country:US
Practice Address - Phone:346-287-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ295134363LP0808X
TX1119120363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health