Provider Demographics
NPI:1174285191
Name:AGBOLOSU, YAO (RN)
Entity Type:Individual
Prefix:
First Name:YAO
Middle Name:
Last Name:AGBOLOSU
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-2737
Mailing Address - Country:US
Mailing Address - Phone:860-833-6928
Mailing Address - Fax:
Practice Address - Street 1:51 PINECREST DR
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-2737
Practice Address - Country:US
Practice Address - Phone:860-833-6928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT143873163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health