Healthcare Provider Details

I. General information

NPI: 1609360411
Provider Name (Legal Business Name): TAIWO TUNDE FAFUNMI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 STACY LYNN LN
YUKON OK
73099-8485
US

IV. Provider business mailing address

9105 STACY LYNN LN
YUKON OK
73099-8485
US

V. Phone/Fax

Practice location:
  • Phone: 405-835-9181
  • Fax:
Mailing address:
  • Phone: 405-835-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: