Provider Demographics
NPI:1053174540
Name:FATADE, ADEMOLA AKINLAYO (OTA)
Entity type:Individual
Prefix:
First Name:ADEMOLA
Middle Name:AKINLAYO
Last Name:FATADE
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-0056
Mailing Address - Country:US
Mailing Address - Phone:850-324-1494
Mailing Address - Fax:850-782-0058
Practice Address - Street 1:2910 W DESOTO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-6161
Practice Address - Country:US
Practice Address - Phone:850-324-1494
Practice Address - Fax:850-782-0058
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19726224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant