Healthcare Provider Details

I. General information

NPI: 1861971897
Provider Name (Legal Business Name): MARY TEMITOPE AJAYI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ADUBI

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W SUNSET RD STE 400
ALAMO HEIGHTS TX
78209-1772
US

IV. Provider business mailing address

10807 PERRIN BEITEL RD
SAN ANTONIO TX
78217-3143
US

V. Phone/Fax

Practice location:
  • Phone: 844-824-8775
  • Fax:
Mailing address:
  • Phone: 210-988-5702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1073422
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number933794
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: