Healthcare Provider Details

I. General information

NPI: 1396633533
Provider Name (Legal Business Name): ABIOLA OGBARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43825 MICHIGAN AVE
CANTON MI
48188-2551
US

IV. Provider business mailing address

9526 REVERE DR
VAN BUREN TOWNSHIP MI
48111-1678
US

V. Phone/Fax

Practice location:
  • Phone: 734-397-3088
  • Fax:
Mailing address:
  • Phone: 734-776-9436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703124204
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: