Provider Demographics
NPI:1598519308
Name:DADA, IDOWU MARIAM
Entity Type:Individual
Prefix:
First Name:IDOWU
Middle Name:MARIAM
Last Name:DADA
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 1:22 HIGH HILL DR
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-2434
Mailing Address - Country:US
Mailing Address - Phone:631-356-6220
Mailing Address - Fax:
Practice Address - Street 1:22 HIGH HILL DR
Practice Address - Street 2:
Practice Address - City:SOUND BEACH
Practice Address - State:NY
Practice Address - Zip Code:11789-2434
Practice Address - Country:US
Practice Address - Phone:631-356-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY814742-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse