Provider Demographics
NPI:1912611781
Name:OLONIMOYO, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:OLONIMOYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-4463
Mailing Address - Country:US
Mailing Address - Phone:718-828-2666
Mailing Address - Fax:
Practice Address - Street 1:142-20 223 ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413
Practice Address - Country:US
Practice Address - Phone:347-553-1349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY829473163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse