Provider Demographics
NPI:1679343164
Name:ADEMODI, OMOTOLA FOLUSHO
Entity type:Individual
Prefix:
First Name:OMOTOLA
Middle Name:FOLUSHO
Last Name:ADEMODI
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 1:231 HAYSTACK AVE
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7356
Mailing Address - Country:US
Mailing Address - Phone:614-787-0059
Mailing Address - Fax:
Practice Address - Street 1:231 HAYSTACK AVE
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-7356
Practice Address - Country:US
Practice Address - Phone:614-787-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant