Provider Demographics
NPI:1346562576
Name:ODUSANYA, VICTORIA IDOWU (RN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:IDOWU
Last Name:ODUSANYA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1443
Mailing Address - Country:US
Mailing Address - Phone:718-774-6343
Mailing Address - Fax:
Practice Address - Street 1:194 PARK AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1443
Practice Address - Country:US
Practice Address - Phone:347-968-9634
Practice Address - Fax:347-968-9634
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY673460163W00000X
NY298102164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000000Medicaid