Provider Demographics
NPI:1902218720
Name:ADESANYA, LATEEF
Entity Type:Individual
Prefix:
First Name:LATEEF
Middle Name:
Last Name:ADESANYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 COLLIER AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2637
Mailing Address - Country:US
Mailing Address - Phone:347-283-7088
Mailing Address - Fax:
Practice Address - Street 1:2224 COLLIER AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2637
Practice Address - Country:US
Practice Address - Phone:347-283-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313598164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse