Provider Demographics
NPI:1205415353
Name:OLEKANMA, FAVOUR
Entity Type:Individual
Prefix:
First Name:FAVOUR
Middle Name:
Last Name:OLEKANMA
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 1:6909 WINTER NIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1471
Mailing Address - Country:US
Mailing Address - Phone:909-251-3146
Mailing Address - Fax:
Practice Address - Street 1:6909 WINTER NIGHT AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1471
Practice Address - Country:US
Practice Address - Phone:909-251-3146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF06200008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily