Provider Demographics
NPI:1750963377
Name:ONANUBOSI, OMOTAYO KEHINDE (FNP-BC)
Entity type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:KEHINDE
Last Name:ONANUBOSI
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:OMOTAYO
Other - Middle Name:KEHINDE
Other - Last Name:AKINREMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12324 S ABBOTT DOWNING WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5693
Mailing Address - Country:US
Mailing Address - Phone:208-283-7062
Mailing Address - Fax:
Practice Address - Street 1:12324 S ABBOTT DOWNING WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5693
Practice Address - Country:US
Practice Address - Phone:208-283-7062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2019011415363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner