Provider Demographics
NPI:1417704032
Name:OJELADE, DIVINE OLUWATOSIN (NP)
Entity type:Individual
Prefix:
First Name:DIVINE
Middle Name:OLUWATOSIN
Last Name:OJELADE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:ADEMUYIWA
Other - Middle Name:
Other - Last Name:OJELADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16675 SHUNING CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-7491
Mailing Address - Country:US
Mailing Address - Phone:310-909-4078
Mailing Address - Fax:
Practice Address - Street 1:24060 FIR AVE STE A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-2895
Practice Address - Country:US
Practice Address - Phone:951-247-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029823363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily