Basic Information
Provider Information
NPI: 1003002189
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OLATUNJI
FirstName: REBECCA
MiddleName: I
NamePrefix:  
NameSuffix:  
Credential: RN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: EKUNDAYO
OtherFirstName: REBECCA
OtherMiddleName: I
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: RN
OtherLastNameType: 1
Mailing Information
Address1: 35 TANTERRA DR
Address2:  
City: STAFFORD
State: VA
PostalCode: 225568007
CountryCode: US
TelephoneNumber: 7038384455
FaxNumber: 7038385070
Practice Location
Address1: 720 N SAINT ASAPH ST
Address2:  
City: ALEXANDRIA
State: VA
PostalCode: 223141912
CountryCode: US
TelephoneNumber: 7038384455
FaxNumber: 7038385070
Other Information
ProviderEnumerationDate: 09/21/2007
LastUpdateDate: 09/21/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000X0001203930VAY Nursing Service ProvidersRegistered Nurse 

ID Information
IDTypeStateIssuerDescription
00494502605VA MEDICAID


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