Provider Demographics
NPI:1811399397
Name:AWELEWA, FUNMI MODUPE
Entity Type:Individual
Prefix:
First Name:FUNMI
Middle Name:MODUPE
Last Name:AWELEWA
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 1:178 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1240
Mailing Address - Country:US
Mailing Address - Phone:631-612-1317
Mailing Address - Fax:
Practice Address - Street 1:178 THOMAS ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1240
Practice Address - Country:US
Practice Address - Phone:631-612-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3177-92164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse