Healthcare Provider Details

I. General information

NPI: 1588991103
Provider Name (Legal Business Name): QUEENSLY AJIBOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14514 226TH ST
SPRINGFIELD GARDENS NY
11413-3534
US

IV. Provider business mailing address

14514 226TH ST
SPRINGFIELD GARDENS NY
11413-3534
US

V. Phone/Fax

Practice location:
  • Phone: 917-330-3740
  • Fax:
Mailing address:
  • Phone: 917-330-3740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF407183-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: