Healthcare Provider Details

I. General information

NPI: 1154970796
Provider Name (Legal Business Name): ADEBOLA KAFAYAT ADEGBENRO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 02/07/2026
Certification Date: 02/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MORNING GLORY DR
LAKE MARY FL
32746-3304
US

IV. Provider business mailing address

205 MORNING GLORY DR
LAKE MARY FL
32746-3304
US

V. Phone/Fax

Practice location:
  • Phone: 214-281-9302
  • Fax:
Mailing address:
  • Phone: 214-281-9302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2360005
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11044371
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1051648
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number349695
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: