Provider Demographics
NPI:1417767690
Name:FAFIOLU, OLUSESAN. A
Entity type:Individual
Prefix:
First Name:OLUSESAN.
Middle Name:A
Last Name:FAFIOLU
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 1:2004 BERRYHILL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-2319
Mailing Address - Country:US
Mailing Address - Phone:717-216-0083
Mailing Address - Fax:
Practice Address - Street 1:2004 BERRYHILL ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-2319
Practice Address - Country:US
Practice Address - Phone:717-216-0083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA80673601253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care