Provider Demographics
NPI:1427406651
Name:OMONIYI, ADEWALE S (NURSE)
Entity Type:Individual
Prefix:MR
First Name:ADEWALE
Middle Name:S
Last Name:OMONIYI
Suffix:
Gender:M
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 S ANGELL ST # 383
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5206
Mailing Address - Country:US
Mailing Address - Phone:401-516-1804
Mailing Address - Fax:866-799-5622
Practice Address - Street 1:11 S ANGELL ST # 383
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5206
Practice Address - Country:US
Practice Address - Phone:401-516-1804
Practice Address - Fax:866-799-5622
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN91103164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse