Provider Demographics
NPI:1265976559
Name:ODUGBEMI, MODUPE BOLANLE (FNP)
Entity type:Individual
Prefix:
First Name:MODUPE
Middle Name:BOLANLE
Last Name:ODUGBEMI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 STEPHENS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2424
Mailing Address - Country:US
Mailing Address - Phone:917-691-1219
Mailing Address - Fax:
Practice Address - Street 1:214 STEPHENS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2424
Practice Address - Country:US
Practice Address - Phone:917-691-1219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF341213-1163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical