Provider Demographics
NPI:1093189029
Name:TIJANI, MODUPE
Entity Type:Individual
Prefix:
First Name:MODUPE
Middle Name:
Last Name:TIJANI
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 1:345 VAN NAME AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2526
Mailing Address - Country:US
Mailing Address - Phone:718-815-0906
Mailing Address - Fax:
Practice Address - Street 1:345 VAN NAME AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2526
Practice Address - Country:US
Practice Address - Phone:718-815-0906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300406-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse