Provider Demographics
NPI:1417793357
Name:OSI, OMOTUNDE
Entity type:Individual
Prefix:
First Name:OMOTUNDE
Middle Name:
Last Name:OSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 CULRIN WAY
Mailing Address - Street 2:
Mailing Address - City:HEARTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75126-3274
Mailing Address - Country:US
Mailing Address - Phone:254-423-8591
Mailing Address - Fax:
Practice Address - Street 1:4515 NORTH RIVER BLVD, NE, SUITE 200
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52411
Practice Address - Country:US
Practice Address - Phone:254-423-8591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA121049237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist