Healthcare Provider Details

I. General information

NPI: 1730052796
Provider Name (Legal Business Name): OLURONKE OMOLOLA FAGBUYI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 LINCOLN AVE APT 6G
BROOKLYN NY
11208-4155
US

IV. Provider business mailing address

765 LINCOLN AVE APT 6G
BROOKLYN NY
11208-4155
US

V. Phone/Fax

Practice location:
  • Phone: 347-837-8713
  • Fax:
Mailing address:
  • Phone: 347-837-8713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number788991
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: