Healthcare Provider Details

I. General information

NPI: 1497317218
Provider Name (Legal Business Name): MOJISOLA OMOLABAKE TALABI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

650 MIX AVE APT 3D
HAMDEN CT
06514-2389
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-6654
  • Fax:
Mailing address:
  • Phone: 585-284-9537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number133819
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: