Provider Demographics
NPI:1609339985
Name:OLUFOWOBI, KIANDRA SADE
Entity Type:Individual
Prefix:
First Name:KIANDRA
Middle Name:SADE
Last Name:OLUFOWOBI
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 1:11063 NW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-2513
Mailing Address - Country:US
Mailing Address - Phone:203-610-9381
Mailing Address - Fax:
Practice Address - Street 1:6001 TOSCANA DR APT 921
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-3591
Practice Address - Country:US
Practice Address - Phone:203-610-9381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program