Provider Demographics
NPI:1396385928
Name:ODUPELU, PATIENCE OGWA
Entity Type:Individual
Prefix:
First Name:PATIENCE
Middle Name:OGWA
Last Name:ODUPELU
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 1:4222 MOOMAW AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-4314
Mailing Address - Country:US
Mailing Address - Phone:540-613-0757
Mailing Address - Fax:
Practice Address - Street 1:4222 MOOMAW AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-4314
Practice Address - Country:US
Practice Address - Phone:540-613-0757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-11
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001231622163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse