Provider Demographics
NPI:1295504462
Name:OSUNLETI, OMOBOLA DEBRAH
Entity type:Individual
Prefix:
First Name:OMOBOLA
Middle Name:DEBRAH
Last Name:OSUNLETI
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 1:3629 BELL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2056
Mailing Address - Country:US
Mailing Address - Phone:718-358-0554
Mailing Address - Fax:
Practice Address - Street 1:3629 BELL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2056
Practice Address - Country:US
Practice Address - Phone:718-358-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352879363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily