Provider Demographics
NPI:1588019467
Name:ODUSANYA, ADEKUNBI OLUWAWEMIMO
Entity Type:Individual
Prefix:MRS
First Name:ADEKUNBI
Middle Name:OLUWAWEMIMO
Last Name:ODUSANYA
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 1:54 DOREEN DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2135
Mailing Address - Country:US
Mailing Address - Phone:718-619-5088
Mailing Address - Fax:
Practice Address - Street 1:54 DOREEN DR
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2135
Practice Address - Country:US
Practice Address - Phone:718-619-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY473041-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse