Provider Demographics
NPI:1902108269
Name:FAKORODE, OMOTAYO
Entity Type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:
Last Name:FAKORODE
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 1:77 FRASER ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6111
Mailing Address - Country:US
Mailing Address - Phone:718-664-3438
Mailing Address - Fax:
Practice Address - Street 1:77 FRASER ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6111
Practice Address - Country:US
Practice Address - Phone:718-664-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263598164W00000X
NY648044163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse