Healthcare Provider Details

I. General information

NPI: 1992011290
Provider Name (Legal Business Name): YETUNDE OGUNBANWO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 WALT WHITMAN RD
HUNTINGTON STATION NY
11746-3612
US

IV. Provider business mailing address

15 WALT WHITMAN RD
HUNTINGTON STATION NY
11746-3612
US

V. Phone/Fax

Practice location:
  • Phone: 917-530-2366
  • Fax:
Mailing address:
  • Phone: 917-530-2366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number614282
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number344099
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number344099
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: