Healthcare Provider Details

I. General information

NPI: 1720805559
Provider Name (Legal Business Name): AFEEZ BABATUNDE GBADAMOSI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6506 BAREBACK TER
NORTH CHESTERFIELD VA
23234-4197
US

IV. Provider business mailing address

6506 BAREBACK TER
NORTH CHESTERFIELD VA
23234-4197
US

V. Phone/Fax

Practice location:
  • Phone: 804-490-3713
  • Fax:
Mailing address:
  • Phone: 804-490-3713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002104892
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: