Provider Demographics
NPI:1306269451
Name:ADEGBENRO, FATAI
Entity type:Individual
Prefix:
First Name:FATAI
Middle Name:
Last Name:ADEGBENRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14140 182ND ST
Mailing Address - Street 2:SPRINGFIELD GARDEN
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-3037
Mailing Address - Country:US
Mailing Address - Phone:347-406-2022
Mailing Address - Fax:
Practice Address - Street 1:14140 182ND ST
Practice Address - Street 2:SPRINGFIELD GARDEN
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-3037
Practice Address - Country:US
Practice Address - Phone:347-406-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY652477-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse