Healthcare Provider Details

I. General information

NPI: 1154620912
Provider Name (Legal Business Name): OLUBUKOLA ELIZABETH AJAYI PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2011
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11606 MYRTLE AVE
RICHMOND HILL NY
11418-1748
US

IV. Provider business mailing address

1441 E 86TH ST
BROOKLYN NY
11236-5133
US

V. Phone/Fax

Practice location:
  • Phone: 718-850-7099
  • Fax:
Mailing address:
  • Phone: 347-217-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN302062
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF4033941
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF403941
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number626867-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: