Provider Demographics
NPI:1598113441
Name:OLUSANYA, BUKOLA DEBORAH
Entity Type:Individual
Prefix:
First Name:BUKOLA
Middle Name:DEBORAH
Last Name:OLUSANYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BUKOLA
Other - Middle Name:DEBORAH
Other - Last Name:AWOSANYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:960 W 62ND PL
Mailing Address - Street 2:APT. 243
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-5474
Mailing Address - Country:US
Mailing Address - Phone:323-440-9196
Mailing Address - Fax:
Practice Address - Street 1:808 W 58TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3632
Practice Address - Country:US
Practice Address - Phone:323-541-1600
Practice Address - Fax:323-541-1499
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004381363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily