Provider Demographics
NPI:1114403730
Name:OSEMWOTA, FAVOUR
Entity type:Individual
Prefix:
First Name:FAVOUR
Middle Name:
Last Name:OSEMWOTA
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 1:10036 203RD ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-3425
Mailing Address - Country:US
Mailing Address - Phone:718-413-8783
Mailing Address - Fax:
Practice Address - Street 1:10036 203RD ST
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423
Practice Address - Country:US
Practice Address - Phone:718-413-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1114403730164W00000X
NY329553164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1114403730Medicaid