Healthcare Provider Details

I. General information

NPI: 1972481364
Provider Name (Legal Business Name): MISTURA OLASUNBO TIAMIYU
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNION ST
LYNN MA
01901-1314
US

IV. Provider business mailing address

76 COBURN ST
LYNN MA
01902-1716
US

V. Phone/Fax

Practice location:
  • Phone: 781-596-2502
  • Fax:
Mailing address:
  • Phone: 781-888-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN10020525
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: