Healthcare Provider Details

I. General information

NPI: 1962722124
Provider Name (Legal Business Name): OLUGBENGA OKUNOYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 TOWNSEND AVE
STATEN ISLAND NY
10304-3713
US

IV. Provider business mailing address

91 TOWNSEND AVE
STATEN ISLAND NY
10304-3713
US

V. Phone/Fax

Practice location:
  • Phone: 347-424-5347
  • Fax: 718-876-0390
Mailing address:
  • Phone: 347-424-5347
  • Fax: 718-876-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number294669
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number294669
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number294669
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: