Provider Demographics
NPI:1407519549
Name:ODETOLA, AGATHA SOWAME
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:SOWAME
Last Name:ODETOLA
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 1:20 W MOSHOLU PKWY S APT 10A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1127
Mailing Address - Country:US
Mailing Address - Phone:347-244-3407
Mailing Address - Fax:
Practice Address - Street 1:2811 QUEENS PLZ N
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4172
Practice Address - Country:US
Practice Address - Phone:718-391-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY805420163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool