Healthcare Provider Details

I. General information

NPI: 1346928454
Provider Name (Legal Business Name): BUKOLA O ADEGBOLA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 CRUTCHFIELD ST
DURHAM NC
27704-2754
US

IV. Provider business mailing address

11361 N 99TH AVE STE 402
PEORIA AZ
85345-5459
US

V. Phone/Fax

Practice location:
  • Phone: 919-560-7305
  • Fax: 919-560-7480
Mailing address:
  • Phone: 602-650-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5018600
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: