Healthcare Provider Details

I. General information

NPI: 1427928431
Provider Name (Legal Business Name): ALLICIA VIVIENNE AJIBOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 SUNSET DR E
JOPLIN MO
64804-1359
US

IV. Provider business mailing address

117 S LEXINGTON ST STE 100
HARRISONVILLE MO
64701-2443
US

V. Phone/Fax

Practice location:
  • Phone: 570-540-2311
  • Fax:
Mailing address:
  • Phone: 816-607-4926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: