Healthcare Provider Details

I. General information

NPI: 1124782115
Provider Name (Legal Business Name): ADIJAT OMOBOLANLE LIGALI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 6TH AVE STE 204
SAN DIEGO CA
92101-5214
US

IV. Provider business mailing address

2350 BUHNE ST
EUREKA CA
95501-3238
US

V. Phone/Fax

Practice location:
  • Phone: 415-671-2165
  • Fax:
Mailing address:
  • Phone: 707-443-4593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95025305
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95186824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: