Provider Demographics
NPI:1629519947
Name:BODUNWA, OMOTAYO
Entity Type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:
Last Name:BODUNWA
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 1:8430 YUCCA LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4671
Mailing Address - Country:US
Mailing Address - Phone:612-481-8047
Mailing Address - Fax:
Practice Address - Street 1:8430 YUCCA LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4671
Practice Address - Country:US
Practice Address - Phone:612-481-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-215202-4374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide