Provider Demographics
NPI:1346880325
Name:BAMGBOSE, LATIFAT OLABISI (LPN)
Entity Type:Individual
Prefix:MS
First Name:LATIFAT
Middle Name:OLABISI
Last Name:BAMGBOSE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 LEHIGH AVENUE
Mailing Address - Street 2:#3
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112
Mailing Address - Country:US
Mailing Address - Phone:862-264-3950
Mailing Address - Fax:
Practice Address - Street 1:233 LEHIGH AVENUE
Practice Address - Street 2:#3
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112
Practice Address - Country:US
Practice Address - Phone:862-264-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07135300164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse