Healthcare Provider Details

I. General information

NPI: 1114334042
Provider Name (Legal Business Name): OLUSHEYI OLOGBAUMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 TEACHERS LN APT 9
ORCHARD PARK NY
14127-4007
US

IV. Provider business mailing address

3885 TEACHERS LN APT 9
ORCHARD PARK NY
14127-4007
US

V. Phone/Fax

Practice location:
  • Phone: 302-824-1451
  • Fax:
Mailing address:
  • Phone: 302-824-1451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number318171
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: