Provider Demographics
NPI:1285784033
Name:ILESANMI, ADEBOLA OMOLARA (FNP)
Entity type:Individual
Prefix:MRS
First Name:ADEBOLA
Middle Name:OMOLARA
Last Name:ILESANMI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 SOUTH M.L.K. JR. DRIVE
Mailing Address - Street 2:ROOM 244
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27110-0001
Mailing Address - Country:US
Mailing Address - Phone:336-750-3300
Mailing Address - Fax:
Practice Address - Street 1:601 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:ROOM 244
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0001
Practice Address - Country:US
Practice Address - Phone:336-750-3300
Practice Address - Fax:336-750-3303
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201969363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593106Medicare PIN