Provider Demographics
NPI:1861110157
Name:AL-EWAIDAT, OLA
Entity type:Individual
Prefix:
First Name:OLA
Middle Name:
Last Name:AL-EWAIDAT
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 1:1011 HULL TER APT 1-1
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3372
Mailing Address - Country:US
Mailing Address - Phone:919-638-1523
Mailing Address - Fax:
Practice Address - Street 1:355 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3328
Practice Address - Country:US
Practice Address - Phone:847-316-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program