Provider Demographics
NPI:1962905323
Name:OLUWADIYA, GRACE A (RN)
Entity type:Individual
Prefix:MS
First Name:GRACE
Middle Name:A
Last Name:OLUWADIYA
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 1:113 N RIPLEY ST APT 101
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-5748
Mailing Address - Country:US
Mailing Address - Phone:708-378-5726
Mailing Address - Fax:
Practice Address - Street 1:21335 SIGNAL HILL PLAZA
Practice Address - Street 2:SUITE 270
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164
Practice Address - Country:US
Practice Address - Phone:703-682-2471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI183983-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA163W00000XMedicaid
163W00000XOther163