Provider Demographics
NPI:1326915646
Name:IDIM, YEMISI HELEN
Entity type:Individual
Prefix:
First Name:YEMISI
Middle Name:HELEN
Last Name:IDIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 MCGOVERN STREET
Mailing Address - Street 2:
Mailing Address - City:TOTTENHAM
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L0G 1W0
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 MCGOVERN STREET
Practice Address - Street 2:
Practice Address - City:TOTTENHAM
Practice Address - State:ONTARIO
Practice Address - Zip Code:L0G 1W0
Practice Address - Country:CA
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306139363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health