Provider Demographics
NPI:1396046652
Name:OBAFEMI, MOFOLUWASO FUNKE
Entity type:Individual
Prefix:
First Name:MOFOLUWASO
Middle Name:FUNKE
Last Name:OBAFEMI
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 1:249 THOMAS BOYLAND STREET
Mailing Address - Street 2:# 23L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-0000
Mailing Address - Country:US
Mailing Address - Phone:347-593-0637
Mailing Address - Fax:
Practice Address - Street 1:249 THOMAS BOYLAND STREET
Practice Address - Street 2:# 23L
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-0000
Practice Address - Country:US
Practice Address - Phone:347-593-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303196-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse