Provider Demographics
NPI:1457819872
Name:JOLAOSO, OMOWUNMI (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:OMOWUNMI
Middle Name:
Last Name:JOLAOSO
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 BOWERY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-1832
Mailing Address - Country:US
Mailing Address - Phone:267-475-8034
Mailing Address - Fax:
Practice Address - Street 1:84 BOWERY ST APT 1
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1832
Practice Address - Country:US
Practice Address - Phone:267-475-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00011342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty