=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073920203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OYERONKE O AJIBOYE-LALA NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2014
-----------------------------------------------------
Last Update Date | 02/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 N DOUGLAS AVE
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85607-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-366-3133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3651 PEACHTREE PARKWAY STE E #234
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-270-0730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP11428
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN201907
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------