Healthcare Provider Details

I. General information

NPI: 1013652528
Provider Name (Legal Business Name): OLANUBI I OWOKA LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 06/12/2022
Certification Date: 06/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 TROUT BROOK ROAD
DRACUT MA
01826
US

IV. Provider business mailing address

65 TROUT BROOK RD
DRACUT MA
01826-4140
US

V. Phone/Fax

Practice location:
  • Phone: 857-249-6930
  • Fax:
Mailing address:
  • Phone: 857-249-6930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLN97119
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: