Healthcare Provider Details

I. General information

NPI: 1841602885
Provider Name (Legal Business Name): AJIBOLA KUTTI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2014
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 MOSEL AVE
STATEN ISLAND NY
10304-3435
US

IV. Provider business mailing address

370 MOSEL AVE
STATEN ISLAND NY
10304-3435
US

V. Phone/Fax

Practice location:
  • Phone: 347-837-9602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number316392
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355544
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: