Provider Demographics
NPI:1548699739
Name:AJE-OMOKORE, OMOTOLU OLAITAN (CNP)
Entity type:Individual
Prefix:MISS
First Name:OMOTOLU
Middle Name:OLAITAN
Last Name:AJE-OMOKORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 N ROCK RD APT 1508
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1185
Mailing Address - Country:US
Mailing Address - Phone:316-990-4126
Mailing Address - Fax:
Practice Address - Street 1:753 N WEST ST, WICHITA, KS 67203
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-685-5691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76179-091364SF0001X
WAAP60590699363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health