Provider Demographics
NPI:1235704370
Name:OWOLABI, BUKOLA ELIZABETH
Entity Type:Individual
Prefix:
First Name:BUKOLA
Middle Name:ELIZABETH
Last Name:OWOLABI
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 1:2404 VIRGINIA AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3376
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2404 VIRGINIA AVE APT 102
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-3376
Practice Address - Country:US
Practice Address - Phone:929-355-9746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00177242376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide