Provider Demographics
NPI:1033656160
Name:FADIYA, OLASUMBO (RN)
Entity Type:Individual
Prefix:
First Name:OLASUMBO
Middle Name:
Last Name:FADIYA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CRAGMERE TER
Mailing Address - Street 2:APT. #1
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2508
Mailing Address - Country:US
Mailing Address - Phone:617-407-5875
Mailing Address - Fax:
Practice Address - Street 1:7 CRAGMERE TER
Practice Address - Street 2:APT. #1
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2508
Practice Address - Country:US
Practice Address - Phone:617-407-5875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN261159363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health