Provider Demographics
NPI:1093052607
Name:ILUYOMADE, KOFOWOROLA A
Entity Type:Individual
Prefix:
First Name:KOFOWOROLA
Middle Name:A
Last Name:ILUYOMADE
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 1:6731 NEW HAMPSHIRE AVE APT 1206
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-2816
Mailing Address - Country:US
Mailing Address - Phone:703-357-0497
Mailing Address - Fax:
Practice Address - Street 1:6731 NEW HAMPSHIRE AVE APT 1206
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-2816
Practice Address - Country:US
Practice Address - Phone:703-357-0497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide