Provider Demographics
NPI:1609419415
Name:OMOTUNDE, MOJISOLA GANIAT
Entity Type:Individual
Prefix:
First Name:MOJISOLA
Middle Name:GANIAT
Last Name:OMOTUNDE
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 1:14805 116TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11436-1306
Mailing Address - Country:US
Mailing Address - Phone:347-264-2034
Mailing Address - Fax:
Practice Address - Street 1:14805 116TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11436-1306
Practice Address - Country:US
Practice Address - Phone:347-264-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY514437163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty