Healthcare Provider Details

I. General information

NPI: 1164334546
Provider Name (Legal Business Name): IMOLEAYO JASOLA ABDUL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 BLUE POINT AVE
BLUE POINT NY
11715-1224
US

IV. Provider business mailing address

93 WOODLAWN AVE
RONKONKOMA NY
11779-5039
US

V. Phone/Fax

Practice location:
  • Phone: 631-419-6737
  • Fax: 631-868-3498
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN25267
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: