Provider Demographics
NPI:1811257868
Name:LIASU, OLUFUNKE YETUNDE
Entity type:Individual
Prefix:MRS
First Name:OLUFUNKE
Middle Name:YETUNDE
Last Name:LIASU
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:OLUFUNKE
Other - Middle Name:YETUNDE
Other - Last Name:AKINBOBOYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3928 SUITLAND RD APT 101
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-1926
Mailing Address - Country:US
Mailing Address - Phone:301-917-4094
Mailing Address - Fax:
Practice Address - Street 1:3928 SUITLAND RD APT 101
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-1926
Practice Address - Country:US
Practice Address - Phone:301-917-4094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374UOOOOOX374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide