Healthcare Provider Details

I. General information

NPI: 1174280549
Provider Name (Legal Business Name): IBUKUN AJOKE FAGBUYI PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IBUKUN AJOKE ONI

II. Dates (important events)

Enumeration Date: 11/20/2021
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13838 S 46TH PL STE 340
PHOENIX AZ
85044-7805
US

IV. Provider business mailing address

9429 W OREGON AVE
GLENDALE AZ
85305-3352
US

V. Phone/Fax

Practice location:
  • Phone: 480-597-7903
  • Fax:
Mailing address:
  • Phone: 301-785-8946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number266910
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: