Healthcare Provider Details

I. General information

NPI: 1285784033
Provider Name (Legal Business Name): ADEBOLA OMOLARA ILESANMI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S MARTIN LUTHER KING JR DR ROOM 244
WINSTON SALEM NC
27110-0001
US

IV. Provider business mailing address

601 SOUTH M.L.K. JR. DRIVE ROOM 244
WINSTON SALEM NC
27110-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-750-3300
  • Fax: 336-750-3303
Mailing address:
  • Phone: 336-750-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201969
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: