Provider Demographics
NPI:1184499873
Name:OLUSHOLA, SIMILOLUWA OLUTOMIWA
Entity type:Individual
Prefix:
First Name:SIMILOLUWA
Middle Name:OLUTOMIWA
Last Name:OLUSHOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIMILOLUWA
Other - Middle Name:OLUTOMIWA
Other - Last Name:OYEBANJO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6344 SUDBURY LN
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-0009
Mailing Address - Country:US
Mailing Address - Phone:817-323-8792
Mailing Address - Fax:
Practice Address - Street 1:415 E AIRPORT FWY
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-6351
Practice Address - Country:US
Practice Address - Phone:972-827-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099886363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health