Healthcare Provider Details

I. General information

NPI: 1083244438
Provider Name (Legal Business Name): FUNBI BOLANLE IWAJOMO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N CAROL BLVD
UPPER DARBY PA
19082-1425
US

IV. Provider business mailing address

117 N CAROL BLVD
UPPER DARBY PA
19082-1425
US

V. Phone/Fax

Practice location:
  • Phone: 267-242-1614
  • Fax:
Mailing address:
  • Phone: 267-242-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: