Specialty |
Taxonomy Code | Specialty Code | Provider Type | |
Family |
363LF0000X | 50 | Nurse Practitioner | |
Pediatrics |
208000000X | 37 | Physician/Pediatric Medicine |
| NPI Number | 1760075667 |
| LBN Legal business name | ADELINE MEMORIAL MEDICAL GROUP PLLC |
| Authorized official | FUNMILOLA ODUTAYO - (PROVIDER) |
| Entity | Organization |
| Organization subpart 1 | No |
| Enumeration date | 02/11/2021 |
| Last updated | 08/06/2025 - About 10 months ago |
| Identifiers | n/a |
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