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 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001203930 | VA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 004945026 | 05 | VA | MEDICAID |