Provider Demographics
NPI:1629685078
Name:RAIMI, SHERIFAT OMOBOLA
Entity Type:Individual
Prefix:
First Name:SHERIFAT
Middle Name:OMOBOLA
Last Name:RAIMI
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 1:8809 NW 84TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-4058
Mailing Address - Country:US
Mailing Address - Phone:405-248-5890
Mailing Address - Fax:
Practice Address - Street 1:8809 NW 84TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-4058
Practice Address - Country:US
Practice Address - Phone:405-248-5891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK127480163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR082294011Medicaid