Healthcare Provider Details

I. General information

NPI: 1568521573
Provider Name (Legal Business Name): OLUFUNMILOLA OGUNMODEDE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3937 IVYWOOD LN
PUEBLO CO
81005-2551
US

IV. Provider business mailing address

PO BOX 9000
PUEBLO CO
81008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-0111
  • Fax: 833-918-2238
Mailing address:
  • Phone: 719-553-0111
  • Fax: 719-553-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0999232
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0999232-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number111416
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: