Healthcare Provider Details

I. General information

NPI: 1598133399
Provider Name (Legal Business Name): FAMILY FIRST NURSE PRACTITIONER IN FAMILY HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11156 76TH DR STE UL1
FOREST HILLS NY
11375-7029
US

IV. Provider business mailing address

11156 76TH DR STE UL1
FOREST HILLS NY
11375-7029
US

V. Phone/Fax

Practice location:
  • Phone: 347-356-4434
  • Fax: 973-779-1696
Mailing address:
  • Phone: 347-356-4434
  • Fax: 973-779-1696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberF333974-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OMOLARA OLANIYI
Title or Position: OWNER
Credential: NP
Phone: 347-356-4434