Provider Demographics
NPI:1740679851
Name:OMOLAJA, BOLA
Entity type:Individual
Prefix:
First Name:BOLA
Middle Name:
Last Name:OMOLAJA
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 1:150 DREISER LOOP
Mailing Address - Street 2:APARTMENT 14F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1931
Mailing Address - Country:US
Mailing Address - Phone:347-579-3437
Mailing Address - Fax:
Practice Address - Street 1:150 DREISER LOOP
Practice Address - Street 2:APARTMENT 14F
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1931
Practice Address - Country:US
Practice Address - Phone:347-579-3437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321062-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse