Provider Demographics
NPI:1891236485
Name:OMOTUNDE-ONIWE, OMOLARA (MS, MED, CDN, LPN)
Entity Type:Individual
Prefix:
First Name:OMOLARA
Middle Name:
Last Name:OMOTUNDE-ONIWE
Suffix:
Gender:F
Credentials:MS, MED, CDN, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137-20 171ST STREET
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434
Mailing Address - Country:US
Mailing Address - Phone:917-748-1524
Mailing Address - Fax:
Practice Address - Street 1:13720 171ST ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4506
Practice Address - Country:US
Practice Address - Phone:917-748-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312344282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital