Provider Demographics
NPI:1568521573
Name:OGUNMODEDE, OLUFUNMILOLA (RN)
Entity type:Individual
Prefix:
First Name:OLUFUNMILOLA
Middle Name:
Last Name:OGUNMODEDE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9000
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-0111
Mailing Address - Fax:719-553-2216
Practice Address - Street 1:3937 IVYWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2551
Practice Address - Country:US
Practice Address - Phone:719-553-0111
Practice Address - Fax:833-918-2238
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0999232363L00000X
COAPN.0999232-NP363LF0000X
CO111416163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21181535Medicaid