Provider Demographics
NPI:1508010851
Name:OMOLE, IBUKUN (ND, LAC)
Entity Type:Individual
Prefix:
First Name:IBUKUN
Middle Name:
Last Name:OMOLE
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 244TH ST SW
Mailing Address - Street 2:STE 111
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5400
Mailing Address - Country:US
Mailing Address - Phone:425-275-5555
Mailing Address - Fax:425-275-5590
Practice Address - Street 1:6005 244TH ST SW
Practice Address - Street 2:STE 111
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-5400
Practice Address - Country:US
Practice Address - Phone:425-275-5555
Practice Address - Fax:425-275-5590
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60039489171100000X
WANT60063074175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath