MEDICARE: AYODELE FAYEMI

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	164W00000X	Licensed Practical Nurse	10307589	NY

General Provider Information

NPI Number	:	1609153212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AYODELE FAYEMI

Provider Business Mailing Address
First Line	:	30 MAXI CT # 2
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-5201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 MAXI CT # 2
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-5201
Country	:	US
Telephone Number	:	718-815-3205
Fax Number	:

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

Provider Enumeration Date	:	11/10/2011
Last Update Date	:	11/10/2011

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Directions to “ AYODELE FAYEMI ” Practice Location

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