Provider Demographics
NPI:1609606029
Name:OBISESAN, FATAI OLUGBENGA
Entity type:Individual
Prefix:
First Name:FATAI
Middle Name:OLUGBENGA
Last Name:OBISESAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5211
Mailing Address - Country:US
Mailing Address - Phone:203-583-5596
Mailing Address - Fax:
Practice Address - Street 1:250 BOSTON AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5211
Practice Address - Country:US
Practice Address - Phone:203-583-5596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY832968163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse