Healthcare Provider Details

I. General information

NPI: 1861989485
Provider Name (Legal Business Name): ADEOLA A OKUNOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 VANDERBILT AVE APT 5H
STATEN ISLAND NY
10304-3533
US

IV. Provider business mailing address

350 VANDERBILT AVE APT 5H
STATEN ISLAND NY
10304-3533
US

V. Phone/Fax

Practice location:
  • Phone: 347-238-8321
  • Fax:
Mailing address:
  • Phone: 347-238-8321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number331518
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: