Provider Demographics
NPI:1427928431
Name:AJIBOLA, ALLICIA VIVIENNE
Entity type:Individual
Prefix:
First Name:ALLICIA
Middle Name:VIVIENNE
Last Name:AJIBOLA
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 1:117 S LEXINGTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-2443
Mailing Address - Country:US
Mailing Address - Phone:816-607-4926
Mailing Address - Fax:
Practice Address - Street 1:3105 SUNSET DR E
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1359
Practice Address - Country:US
Practice Address - Phone:570-540-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO253Z00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care