Provider Demographics
NPI:1538872122
Name:ADESANYA, OLUTOYIN
Entity type:Individual
Prefix:
First Name:OLUTOYIN
Middle Name:
Last Name:ADESANYA
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 1:6034 HAMILTON BLVD
Mailing Address - Street 2:PMB 1105
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106
Mailing Address - Country:US
Mailing Address - Phone:484-268-2728
Mailing Address - Fax:
Practice Address - Street 1:6034 HAMILTON BLVD
Practice Address - Street 2:PMB 1105
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106
Practice Address - Country:US
Practice Address - Phone:484-268-2728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027216363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health