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General NPI Number Information
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NPI Number | 1285784033
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Entity Type | Individual
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Provider Name | ADEBOLA OMOLARA ILESANMI FNP
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Gender | Female
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 01/13/2009
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Provider Practice Location Address
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Address Line | 601 S MARTIN LUTHER KING JR DR ROOM 244
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City | WINSTON SALEM
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State | NC
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Zip | 27110-0001
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Country | US
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Telephone | 336-750-3300
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Fax | 336-750-3303
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Provider Business Mailing Address
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Address Line | 601 SOUTH M.L.K. JR. DRIVE ROOM 244
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City | WINSTON SALEM
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State | NC
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Zip | 27110-0001
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Country | US
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Telephone | 336-750-3300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 201969
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License Number State | NC
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