Provider Demographics
NPI:1972948966
Name:AMON, BOLANLE TINUKE (FCNP)
Entity Type:Individual
Prefix:
First Name:BOLANLE
Middle Name:TINUKE
Last Name:AMON
Suffix:
Gender:F
Credentials:FCNP
Other - Prefix:
Other - First Name:BOLA
Other - Middle Name:TINUKE
Other - Last Name:AMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FCNP
Mailing Address - Street 1:725 WICKER AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-7251
Mailing Address - Country:US
Mailing Address - Phone:215-639-4646
Mailing Address - Fax:215-639-2323
Practice Address - Street 1:725 WICKER AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-7251
Practice Address - Country:US
Practice Address - Phone:215-639-4646
Practice Address - Fax:215-639-2323
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA568664163W00000X
NJ26NR11110200163W00000X
PASP012757363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA017673OtherPRESCRIPTIVE AUTHORITY (BUREAU OF PROFESSIONAL & OCCUPATIONAL AFFAIRS)
PASP012757OtherPA CERTIFIED REGISTERED NURSE PRACTIONER (FAMILY HEALTH)
PA568664OtherREGISTERED NURSE