Provider Demographics
NPI:1821395575
Name:OLUSEMO, OLUBUKOLA GRACE (RN)
Entity Type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:GRACE
Last Name:OLUSEMO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6680 MOREHAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-5096
Mailing Address - Country:US
Mailing Address - Phone:614-604-8704
Mailing Address - Fax:
Practice Address - Street 1:6680 MOREHAMPTON CT
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-5096
Practice Address - Country:US
Practice Address - Phone:614-604-8704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH338593163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse