Provider Demographics
NPI:1629210448
Name:KASSIM, OMOLARA
Entity Type:Individual
Prefix:
First Name:OMOLARA
Middle Name:
Last Name:KASSIM
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 1:40 W MOSHOLU PKWY S
Mailing Address - Street 2:APT #5-L
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 W MOSHOLU PKWY S
Practice Address - Street 2:APT #5-L
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-1150
Practice Address - Country:US
Practice Address - Phone:443-763-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274025164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse