Provider Demographics
NPI:1700134681
Name:FAFOWORA, CHINYELU LILY
Entity Type:Individual
Prefix:
First Name:CHINYELU
Middle Name:LILY
Last Name:FAFOWORA
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 1:21038 NASHVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11411-1043
Mailing Address - Country:US
Mailing Address - Phone:646-262-0168
Mailing Address - Fax:
Practice Address - Street 1:21038 NASHVILLE BLVD
Practice Address - Street 2:
Practice Address - City:CAMBRIA HTS
Practice Address - State:NY
Practice Address - Zip Code:11411-1043
Practice Address - Country:US
Practice Address - Phone:646-262-0168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1114570174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist