Healthcare Provider Details

I. General information

NPI: 1093189029
Provider Name (Legal Business Name): MODUPE TIJANI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 VAN NAME AVE
STATEN ISLAND NY
10303-2526
US

IV. Provider business mailing address

345 VAN NAME AVE
STATEN ISLAND NY
10303-2526
US

V. Phone/Fax

Practice location:
  • Phone: 718-815-0906
  • Fax:
Mailing address:
  • Phone: 718-815-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number300406-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: