Provider Demographics
NPI:1811369424
Name:BALOGUN, OMOWUNMI
Entity Type:Individual
Prefix:
First Name:OMOWUNMI
Middle Name:
Last Name:BALOGUN
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 1:1717 N VERDUGO RD
Mailing Address - Street 2:APT 161
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2934
Mailing Address - Country:US
Mailing Address - Phone:310-279-2818
Mailing Address - Fax:
Practice Address - Street 1:1717 N VERDUGO RD
Practice Address - Street 2:APT 161
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-2934
Practice Address - Country:US
Practice Address - Phone:310-279-2818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily