Healthcare Provider Details

I. General information

NPI: 1669993358
Provider Name (Legal Business Name): OLOLADE OLAMIDE OBAFEMI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12954 HAWTHORNE BOULEVARD, SUITE 104 HAWTHORNE MORNINGSIDE MEDICAL CLINIC
HAWTHORNE CA
90250
US

IV. Provider business mailing address

644 COLORADO CIR
CARSON CA
90745-2855
US

V. Phone/Fax

Practice location:
  • Phone: 310-679-0269
  • Fax:
Mailing address:
  • Phone: 310-985-5794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95005741
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: