Provider Demographics
NPI:1710232798
Name:KOLAWOLE, FUNMILOLA AZEEZAT (LPN)
Entity Type:Individual
Prefix:
First Name:FUNMILOLA
Middle Name:AZEEZAT
Last Name:KOLAWOLE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 LOCKMAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2022
Mailing Address - Country:US
Mailing Address - Phone:347-666-0278
Mailing Address - Fax:
Practice Address - Street 1:85 LOCKMAN AV
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303
Practice Address - Country:US
Practice Address - Phone:347-666-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3059521164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse