Healthcare Provider Details

I. General information

NPI: 1720278872
Provider Name (Legal Business Name): BOLA D AJIBOLA NUTRITIONIST, CWP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 14TH AVE N
NASHVILLE TN
37208-3050
US

IV. Provider business mailing address

PO BOX 1127
MOUNT JULIET TN
37121-1127
US

V. Phone/Fax

Practice location:
  • Phone: 615-294-5122
  • Fax:
Mailing address:
  • Phone: 615-294-5122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: