Healthcare Provider Details

I. General information

NPI: 1801715941
Provider Name (Legal Business Name): AZIBATARAM BENEDICTA FATOYE-ALAGOA LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

IV. Provider business mailing address

6304 N 80TH ST
OMAHA NE
68134-8100
US

V. Phone/Fax

Practice location:
  • Phone: 402-939-7838
  • Fax: 612-725-1219
Mailing address:
  • Phone: 402-930-7838
  • Fax: 612-725-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number22964
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: