Shola Adewunmi, PMHNP | NPI 1073168449

Key facts

NPI: 1073168449
Entity type: Individual (NPI type 1)
Primary specialty: Psychiatric/Mental Health Nurse Practitioner 363LP0808X
License: AP61063594 (WA)
Practice address: 6115 Burden Blvd Ste D
Pasco, WA 99301-0010
Phone: (509) 488-5256
Fax: (509) 488-9939
NPI assigned: Aug 2, 2019
Sex: Male
Sole proprietor: No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Lifesource of North Carolina General Practice Physician · Rome, GA · NPI 1962940817

Medicare reassignment GA

Medicare participation

Medicare fee-for-service enrollment: Enrolled in GA
Eligible to order & refer: Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
I20191023003551	GA	Practitioner - Nurse Practitioner	4082946074	Reassigns benefits to 1 organization

National Provider Directory

Medicare enrollment (NPD): Yes
Credentials: Nurse Practitioner

State licenses

License	State	Type	Specialty
AC002778	MD	MD	Psychiatric/Mental Health Nurse Practitioner

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Psychiatric/Mental Health Nurse Practitioner	363LP0808X	AC002778	MD
Psychiatric/Mental Health Nurse Practitioner	363LP0808X	AP61063594	WA	Yes

Addresses

Primary practice location

6115 Burden Blvd Ste D
Pasco, WA 99301-0010

Mailing address

1515 E Columbia St
Othello, WA 99344-1846
Phone (509) 488-5256

Other practice location 1

1515 E Columbia St
Othello, WA 99344-1846
Phone (509) 488-5256

Other practice location 2

1051 Columbia Ave
Connell, WA 99326-8702
Phone (509) 488-5256

Other practice location 3

601 Government Rd
Mattawa, WA 99349-5120
Phone (509) 488-5256

Other practice location 4

14723 London Ln
Bowie, MD 20715-2548
Phone (404) 902-9180

Other practice location 5

1345 Redmond Cir NW
Rome, GA 30165-1307
Phone (910) 742-9243

Other practice location 6

6115 Burden Blvd Ste D
Pasco, WA 99301-0010
Phone (509) 488-5256

Other identifiers

Identifier	Type	State	Issuer
AP61063594	Other	WA	WA ST. DEPT. OF HEALTH
RN61063515	Other	WA	WA. ST. DEPT. OF HEALTH

Other providers in Pasco, WA

A Plus Interpreters
Melissa Abel, RN
Accident Care Chiropractic and Massage of Pasco, PC
Accident Chiropractic of Pasco
Eli A. Adamian, MD
Advantagepoint Health Alliance - Northwest, LLC
Joy Aerts
Katavera Ahlgreen
Dheeraj Ahuja, MD
David Ainscow, B.A.B.S.

All providers in Pasco, WA · Psychiatric/Mental Health Nurse Practitioner in Washington

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 29, 2024. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
Order and Referring (CMS).
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.