MEDICARE: QUEEN TABITHA BOLORUNDURO

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	N22617	NY

General Provider Information

NPI Number	:	1891647319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUEEN TABITHA BOLORUNDURO

Provider Business Mailing Address
First Line	:	6424 18TH AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-3729
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6424 18TH AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-3729
Country	:	US
Telephone Number	:	929-331-6515
Fax Number	:

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

Provider Enumeration Date	:	02/10/2026
Last Update Date	:	02/10/2026

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Directions to “ QUEEN TABITHA BOLORUNDURO ” Practice Location

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