Provider Demographics
NPI:1033688569
Name:OLUYOMI, SHADE MARY
Entity Type:Individual
Prefix:
First Name:SHADE
Middle Name:MARY
Last Name:OLUYOMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MANOR DR APT 15D
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3241
Mailing Address - Country:US
Mailing Address - Phone:908-374-8227
Mailing Address - Fax:
Practice Address - Street 1:89 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4463
Practice Address - Country:US
Practice Address - Phone:718-828-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY729346163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse