1962905323 NPI number — MS. GRACE A OLUWADIYA RN

Table of content: MS. GRACE A OLUWADIYA RN (NPI 1962905323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962905323 NPI number — MS. GRACE A OLUWADIYA RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLUWADIYA
Provider First Name:
GRACE
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962905323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 N RIPLEY ST APT 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22304-5748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-378-5726
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21335 SIGNAL HILL PLAZA
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-682-2471
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2018

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: 163W00000X , with the licence number:  183983-30 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 163W00000X , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 163W00000X . This is a "163" identifier . This identifiers is of the category "OTHER".




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