Basic Information
| Provider Information | |||||||||
| NPI: | 1871842161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DARAMOLA | ||||||||
| FirstName: | OLUBUSOLA | ||||||||
| MiddleName: | TEMIDAYO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6080 S HULEN ST | ||||||||
| Address2: | SUITE 360 PMB 229 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761322622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644262306 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 206 WALLS DR | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760334045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176450668 | ||||||||
| FaxNumber: | 8176450720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2012 | ||||||||
| LastUpdateDate: | 06/02/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 824556 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | DO7564 | 01 | TX | RR GROUP | OTHER | P01111340 | 01 | TX | RR MEDICARE PTAN | OTHER | 2035487-04 | 05 | TX | MEDICAID | 3089625-01 | 05 | TX | MEDICAID | 890N47 | 01 | TX | BCBS PTAN | OTHER |