Healthcare Provider Details

I. General information

NPI: 1295550820
Provider Name (Legal Business Name): ABIMBOLA MARY IWEGBULAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

IV. Provider business mailing address

268 STILLWATER AVE
BANGOR ME
04401-3980
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP241242
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN73841
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: