Provider Demographics
NPI:1154136141
Name:OMOYENI, KOLADE BENSON (MBA)
Entity type:Individual
Prefix:
First Name:KOLADE
Middle Name:BENSON
Last Name:OMOYENI
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 RIVER WAY CT APT 102
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5720
Mailing Address - Country:US
Mailing Address - Phone:646-229-4597
Mailing Address - Fax:
Practice Address - Street 1:205 RIVER WAY CT APT 102
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5720
Practice Address - Country:US
Practice Address - Phone:646-229-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-08
Last Update Date:2025-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0056032163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty