Provider Demographics
NPI:1124782115
Name:LIGALI, ADIJAT OMOBOLANLE
Entity type:Individual
Prefix:
First Name:ADIJAT
Middle Name:OMOBOLANLE
Last Name:LIGALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 6TH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5214
Mailing Address - Country:US
Mailing Address - Phone:415-671-2165
Mailing Address - Fax:
Practice Address - Street 1:25000 AVENUE STANFORD STE 167
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4596
Practice Address - Country:US
Practice Address - Phone:818-600-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95186824163W00000X
CA95025305363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse