Provider Demographics
NPI:1669946588
Name:OLAOSEBIKAN, OLUSEGUN (DNP, MS, MPH, APRN-C)
Entity type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:
Last Name:OLAOSEBIKAN
Suffix:
Gender:M
Credentials:DNP, MS, MPH, APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2491
Mailing Address - Street 2:
Mailing Address - City:VERNON ROCKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06066-8591
Mailing Address - Country:US
Mailing Address - Phone:316-204-0504
Mailing Address - Fax:
Practice Address - Street 1:1 EMERSON DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-3204
Practice Address - Country:US
Practice Address - Phone:860-688-6443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8056363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner