Healthcare Provider Details

I. General information

NPI: 1710524517
Provider Name (Legal Business Name): OLUFUNKE OLUDAYO OBADINA RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2019
Last Update Date: 11/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 BEACH 65TH ST
ARVERNE NY
11692-1354
US

IV. Provider business mailing address

519 BEACH 65TH ST
ARVERNE NY
11692-1354
US

V. Phone/Fax

Practice location:
  • Phone: 718-415-6979
  • Fax:
Mailing address:
  • Phone: 718-415-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number009634-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: