Healthcare Provider Details

I. General information

NPI: 1922822659
Provider Name (Legal Business Name): ADETUNJI ADENIPEKUN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 ROPER MOUNTAIN RD APT 538
GREENVILLE SC
29615-5174
US

IV. Provider business mailing address

1409 ROPER MOUNTAIN RD APT 538
GREENVILLE SC
29615-5174
US

V. Phone/Fax

Practice location:
  • Phone: 312-834-9016
  • Fax:
Mailing address:
  • Phone: 312-834-9016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number30602A
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: