Basic Information
| Provider Information | |||||||||
| NPI: | 1669946588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLAOSEBIKAN | ||||||||
| FirstName: | OLUSEGUN | ||||||||
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| Credential: | MS,MPH,APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CHESTNUT HILL RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD SPRINGS | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060764005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606844251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 EMERSON DR | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060953204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606886443 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2019 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 8056 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.