Provider Demographics
NPI:1295982064
Name:OSOFISAN, OLUSOLA E (LPN)
Entity type:Individual
Prefix:MR
First Name:OLUSOLA
Middle Name:E
Last Name:OSOFISAN
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SMITH LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1851
Mailing Address - Country:US
Mailing Address - Phone:631-846-1406
Mailing Address - Fax:
Practice Address - Street 1:4 SMITH LN
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1851
Practice Address - Country:US
Practice Address - Phone:631-846-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290767164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse