Healthcare Provider Details

I. General information

NPI: 1255689824
Provider Name (Legal Business Name): ADEBUKOLA AINA ADENIRAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BUKOLA AINA ADENIRAN

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E MAIN ST STE 1B
BABYLON NY
11702-3517
US

IV. Provider business mailing address

133 E MAIN ST STE 1B
BABYLON NY
11702-3517
US

V. Phone/Fax

Practice location:
  • Phone: 631-482-9880
  • Fax: 631-482-9911
Mailing address:
  • Phone: 631-482-9880
  • Fax: 631-482-9911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number553296-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number306216
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: