Provider Demographics
NPI:1598082091
Name:BOSEDE, OLUSEGUN J (LPN)
Entity Type:Individual
Prefix:MR
First Name:OLUSEGUN
Middle Name:J
Last Name:BOSEDE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-1306
Mailing Address - Country:US
Mailing Address - Phone:347-891-5231
Mailing Address - Fax:
Practice Address - Street 1:217 HAWTHORNE AVE
Practice Address - Street 2:APT 8
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-1306
Practice Address - Country:US
Practice Address - Phone:347-891-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290933-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse