Provider Demographics
NPI:1003139023
Name:FAWOLE, LAWRENCE OLALERE (LPN)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:OLALERE
Last Name:FAWOLE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ARLINGTON AVE BSMT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1601
Mailing Address - Country:US
Mailing Address - Phone:718-442-1463
Mailing Address - Fax:
Practice Address - Street 1:47 ARLINGTON AVE BSMT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-1601
Practice Address - Country:US
Practice Address - Phone:718-442-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290415-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse