Provider Demographics
NPI:1598407157
Name:OLUGBODE, EDITH O (FNP)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:O
Last Name:OLUGBODE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 LEO AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-1223
Mailing Address - Country:US
Mailing Address - Phone:401-516-4418
Mailing Address - Fax:
Practice Address - Street 1:333 BUDLONG RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6337
Practice Address - Country:US
Practice Address - Phone:401-943-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN03038363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily