Provider Demographics
NPI:1407195423
Name:OLATUNJI-IKUOMENISAN, TAIWO KALEJAIYE (LPN)
Entity type:Individual
Prefix:MR
First Name:TAIWO
Middle Name:KALEJAIYE
Last Name:OLATUNJI-IKUOMENISAN
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133A COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1221
Mailing Address - Country:US
Mailing Address - Phone:631-827-5675
Mailing Address - Fax:
Practice Address - Street 1:133A COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1221
Practice Address - Country:US
Practice Address - Phone:631-827-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313350-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse