Provider Demographics
NPI:1609560416
Name:EGBETOLA, TAIWO T (RN)
Entity Type:Individual
Prefix:MS
First Name:TAIWO
Middle Name:T
Last Name:EGBETOLA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TAIWO
Other - Middle Name:T
Other - Last Name:ISOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:2406 WILDWIND RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2406 WILDWIND RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-5503
Practice Address - Country:US
Practice Address - Phone:800-831-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM58514163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse