Provider Demographics
NPI:1164994711
Name:BOLAJI, TINA O
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:O
Last Name:BOLAJI
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 1:11835 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7200
Mailing Address - Country:US
Mailing Address - Phone:718-657-7770
Mailing Address - Fax:
Practice Address - Street 1:11835 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7200
Practice Address - Country:US
Practice Address - Phone:718-657-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker