Healthcare Provider Details

I. General information

NPI: 1073003976
Provider Name (Legal Business Name): MISS OMOTUNDE ADEMOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 TABOR AVE
PHILADELPHIA PA
19120-2124
US

IV. Provider business mailing address

3000 FORD RD APT K23
BRISTOL PA
19007-1464
US

V. Phone/Fax

Practice location:
  • Phone: 215-245-2131
  • Fax:
Mailing address:
  • Phone: 856-220-8488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN295126
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: