MEDICARE: OMOFOLARIN DEBELLOTTE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	737775-1	NY

General Provider Information

NPI Number	:	1568089183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMOFOLARIN DEBELLOTTE RN

Provider Business Mailing Address
First Line	:	582 BRADFORD ST APT 2R
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-5926
Country	:	US
Telephone Number	:	718-313-6889
Fax Number	:

Provider Business Practice Location Address
First Line	:	582 BRADFORD ST APT 2R
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-5926
Country	:	US
Telephone Number	:	718-313-6889
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2020
Last Update Date	:	06/30/2020

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