Healthcare Provider Details

I. General information

NPI: 1558281667
Provider Name (Legal Business Name): BOLA ADIJAT ADEYEMI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2026
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SCARBORO AVE
STATEN ISLAND NY
10305-3118
US

IV. Provider business mailing address

185 DONGAN ST
STATEN ISLAND NY
10310-1909
US

V. Phone/Fax

Practice location:
  • Phone: 718-551-8932
  • Fax:
Mailing address:
  • Phone: 347-208-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number355625
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: