Provider Demographics
NPI:1831460609
Name:ASHADE, AMUDALAT ADENIKE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:AMUDALAT
Middle Name:ADENIKE
Last Name:ASHADE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 NORTHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1624
Mailing Address - Country:US
Mailing Address - Phone:347-938-4978
Mailing Address - Fax:
Practice Address - Street 1:103 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-1624
Practice Address - Country:US
Practice Address - Phone:347-938-4978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308944164W00000X
NY77485163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse