Provider Demographics
NPI:1063779395
Name:ALAWODE, OMOTAYO MARY
Entity type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:MARY
Last Name:ALAWODE
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 1:324 BEACH 59TH ST
Mailing Address - Street 2:APT 3A
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1648
Mailing Address - Country:US
Mailing Address - Phone:718-474-4146
Mailing Address - Fax:
Practice Address - Street 1:324 BEACH 59TH ST
Practice Address - Street 2:APT 3A
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1648
Practice Address - Country:US
Practice Address - Phone:718-474-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309075164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse