Provider Demographics
NPI:1386460830
Name:ADETOLA, IYABODE ADENIKE (FNP)
Entity type:Individual
Prefix:
First Name:IYABODE
Middle Name:ADENIKE
Last Name:ADETOLA
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 1:136 DADFORD DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5801
Mailing Address - Country:US
Mailing Address - Phone:229-395-1395
Mailing Address - Fax:
Practice Address - Street 1:146 CCA RD
Practice Address - Street 2:
Practice Address - City:LUMPKIN
Practice Address - State:GA
Practice Address - Zip Code:31815-3823
Practice Address - Country:US
Practice Address - Phone:229-838-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177864363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily