Healthcare Provider Details

I. General information

NPI: 1073775664
Provider Name (Legal Business Name): OLUFUNMILAYO OLUREMI OGUNNAIYA R.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 ADAMS LN
MIDDLE ISLAND NY
11953-1803
US

IV. Provider business mailing address

14 ADAMS LN
MIDDLE ISLAND NY
11953-1803
US

V. Phone/Fax

Practice location:
  • Phone: 631-698-0989
  • Fax: 631-698-0989
Mailing address:
  • Phone: 631-698-0989
  • Fax: 631-698-0989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number550343-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: