Healthcare Provider Details

I. General information

NPI: 1104043595
Provider Name (Legal Business Name): ADETUTU A OLOMOLA R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 MASSACHUSETTS AVE
BOSTON MA
02118-2318
US

IV. Provider business mailing address

729 MASSACHUSETTS AVE
BOSTON MA
02118-2318
US

V. Phone/Fax

Practice location:
  • Phone: 857-654-1000
  • Fax: 617-414-5418
Mailing address:
  • Phone: 857-654-1000
  • Fax: 617-414-5418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number253255
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: