Provider Demographics
NPI:1144470923
Name:ALLI-BALOGUN, TAWA
Entity type:Individual
Prefix:
First Name:TAWA
Middle Name:
Last Name:ALLI-BALOGUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAWA
Other - Middle Name:
Other - Last Name:YUSSUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47 MCKEEVER PL
Mailing Address - Street 2:APT 21-H
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-2555
Mailing Address - Country:US
Mailing Address - Phone:718-735-6852
Mailing Address - Fax:
Practice Address - Street 1:47 MCKEEVER PL
Practice Address - Street 2:APT 21-H
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-2555
Practice Address - Country:US
Practice Address - Phone:718-735-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290361164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse