Provider Demographics
NPI:1053995357
Name:ODEDAIRO, ABIMBOLA (PMHNP)
Entity type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:ODEDAIRO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18350 ARCOLA BAY LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-1112
Mailing Address - Country:US
Mailing Address - Phone:713-534-3545
Mailing Address - Fax:
Practice Address - Street 1:18350 ARCOLA BAY LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-1112
Practice Address - Country:US
Practice Address - Phone:713-534-3545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1021025363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health