Provider Demographics
NPI:1235496043
Name:ODELADE, KUBURAT
Entity Type:Individual
Prefix:
First Name:KUBURAT
Middle Name:
Last Name:ODELADE
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 1:5715 SHORE FRONT PKWY
Mailing Address - Street 2:APT 1509
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1883
Mailing Address - Country:US
Mailing Address - Phone:718-350-8741
Mailing Address - Fax:
Practice Address - Street 1:5715 SHORE FRONT PKWY
Practice Address - Street 2:APT 1509
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1883
Practice Address - Country:US
Practice Address - Phone:718-350-8741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY650598163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse