MEDICARE: MS. TAIWO FAUSAT BOLARINWA NURSE

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	164W00000X	Licensed Practical Nurse	295967	NY

General Provider Information

NPI Number	:	1841057015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TAIWO FAUSAT BOLARINWA NURSE

Provider Business Mailing Address
First Line	:	3325 FENTON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-2805
Country	:	US
Telephone Number	:	917-375-9754
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 FOREST AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-7802
Country	:	US
Telephone Number	:	718-401-5788
Fax Number	:

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

Provider Enumeration Date	:	03/04/2024
Last Update Date	:	03/04/2024

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