MEDICARE: KUBURAT ODELADE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	650598	NY

General Provider Information

NPI Number	:	1235496043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KUBURAT ODELADE

Provider Business Mailing Address
First Line	:	5715 SHORE FRONT PKWY
Second Line	:	APT 1509
City	:	ARVERNE
State	:	NY
Zip	:	11692-1883
Country	:	US
Telephone Number	:	718-350-8741
Fax Number	:

Provider Business Practice Location Address
First Line	:	5715 SHORE FRONT PKWY
Second Line	:	APT 1509
City	:	ARVERNE
State	:	NY
Zip	:	11692-1883
Country	:	US
Telephone Number	:	718-350-8741
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2012
Last Update Date	:	04/18/2012

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