Healthcare Provider Details

I. General information

NPI: 1013425768
Provider Name (Legal Business Name): OLIVIA MAAMLE OBUABANG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KNIGHTSBRIDGE UNIT E
POUGHKEEPSIE NY
12603-3641
US

IV. Provider business mailing address

12 KNIGHTSBRIDGE UNIT E
POUGHKEEPSIE NY
12603-3641
US

V. Phone/Fax

Practice location:
  • Phone: 646-245-9527
  • Fax:
Mailing address:
  • Phone: 646-245-9527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF342394-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: