Healthcare Provider Details

I. General information

NPI: 1902108269
Provider Name (Legal Business Name): OMOTAYO FAKORODE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 FRASER ST
STATEN ISLAND NY
10314-6111
US

IV. Provider business mailing address

77 FRASER ST
STATEN ISLAND NY
10314-6111
US

V. Phone/Fax

Practice location:
  • Phone: 718-664-3438
  • Fax:
Mailing address:
  • Phone: 718-664-3438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number263598
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number648044
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: