1881174654 NPI number — FAUSAT FUNMILOLA ODUBIYI NURSE PRACTITIONER

Table of content: FAUSAT FUNMILOLA ODUBIYI NURSE PRACTITIONER (NPI 1881174654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881174654 NPI number — FAUSAT FUNMILOLA ODUBIYI NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODUBIYI
Provider First Name:
FAUSAT
Provider Middle Name:
FUNMILOLA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FATOKUN
Provider Other First Name:
FAUSAT
Provider Other Middle Name:
FUNMILOLA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881174654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 2B
Provider Business Mailing Address City Name:
RANCOCAS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08073-2735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-471-3560
Provider Business Mailing Address Fax Number:
833-520-1488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANCOCAS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-471-3560
Provider Business Practice Location Address Fax Number:
833-520-1488
Provider Enumeration Date:
08/21/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  26NR22474600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 402510 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)