Provider Demographics
NPI:1215370697
Name:TIAMIYU, OLUSHOLA MELANIE
Entity Type:Individual
Prefix:
First Name:OLUSHOLA
Middle Name:MELANIE
Last Name:TIAMIYU
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 1:18613 JAMAICA AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2413
Mailing Address - Country:US
Mailing Address - Phone:404-307-4981
Mailing Address - Fax:
Practice Address - Street 1:18613 JAMAICA AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2413
Practice Address - Country:US
Practice Address - Phone:404-307-4981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA95321363A00000X
NY016490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant