Provider Demographics
NPI:1609148352
Name:OMOALDUN, MOJISOLA I (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MOJISOLA
Middle Name:
Last Name:OMOALDUN
Suffix:I
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1666
Mailing Address - Country:US
Mailing Address - Phone:646-258-8069
Mailing Address - Fax:
Practice Address - Street 1:141 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-1666
Practice Address - Country:US
Practice Address - Phone:646-258-8069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308-567-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse