Provider Demographics
NPI:1801586649
Name:FASHOLA, OMOWUMI M
Entity type:Individual
Prefix:
First Name:OMOWUMI
Middle Name:M
Last Name:FASHOLA
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 1:1480 US HIGHWAY 46 APT 216B
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-1923
Mailing Address - Country:US
Mailing Address - Phone:862-588-9121
Mailing Address - Fax:
Practice Address - Street 1:1480 US HIGHWAY 46 APT 216B
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-1923
Practice Address - Country:US
Practice Address - Phone:862-588-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY874979390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program