Provider Demographics
NPI:1508079294
Name:MIKOKU, YEWANDE TEMITOPE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:YEWANDE
Middle Name:TEMITOPE
Last Name:MIKOKU
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MISS
Other - First Name:YEWANDE
Other - Middle Name:TEMITOPE
Other - Last Name:MAKANJUOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1938
Mailing Address - Country:US
Mailing Address - Phone:917-841-6757
Mailing Address - Fax:
Practice Address - Street 1:27 DIXON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1938
Practice Address - Country:US
Practice Address - Phone:917-841-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403469363L00000X, 363LP0808X
NY559805-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health