Provider Demographics
NPI:1982479374
Name:MOMODU, PRINCE SHAKA
Entity Type:Individual
Prefix:
First Name:PRINCE
Middle Name:SHAKA
Last Name:MOMODU
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 1:315 DEADERICK ST STE 1550
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37238-3003
Mailing Address - Country:US
Mailing Address - Phone:615-554-2292
Mailing Address - Fax:
Practice Address - Street 1:315 DEADERICK ST STE 1550
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37238-3003
Practice Address - Country:US
Practice Address - Phone:615-554-2292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care