Healthcare Provider Details

I. General information

NPI: 1467025056
Provider Name (Legal Business Name): THEOPHILUS AKINOLA SANGODELE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 CLIFTON AVE STE 305
CINCINNATI OH
45220-3047
US

IV. Provider business mailing address

3219 CLIFTON AVE STE 305
CINCINNATI OH
45220-3047
US

V. Phone/Fax

Practice location:
  • Phone: 513-346-1270
  • Fax: 513-489-1526
Mailing address:
  • Phone: 513-346-1270
  • Fax: 513-489-1526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11014429
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0029670
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: