Basic Information
| Provider Information | |||||||||
| NPI: | 1073997938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLUWAFEMI | ||||||||
| FirstName: | YANIQUE | ||||||||
| MiddleName: | KAYANA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 EAST STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETH SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19348 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9109 LIBERTY RD | ||||||||
| Address2: | PATAPSCO VALLEY CENTER | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106557373 | ||||||||
| FaxNumber: | 4106550348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2015 | ||||||||
| LastUpdateDate: | 07/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2256 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 22458 | 01 | MD | PT LICENSE | OTHER |