Provider Demographics
NPI:1437399672
Name:SHAW, OMOLOLA
Entity Type:Individual
Prefix:
First Name:OMOLOLA
Middle Name:
Last Name:SHAW
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 1:49 CROWN ST
Mailing Address - Street 2:APT 23C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-1855
Mailing Address - Country:US
Mailing Address - Phone:718-493-7456
Mailing Address - Fax:
Practice Address - Street 1:49 CROWN ST
Practice Address - Street 2:APT 23C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-1855
Practice Address - Country:US
Practice Address - Phone:718-493-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-28
Last Update Date:2009-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292367-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse