Provider Demographics
NPI:1588991103
Name:AJIBOLA, QUEENSLY
Entity type:Individual
Prefix:
First Name:QUEENSLY
Middle Name:
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 1:14514 226TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-3534
Mailing Address - Country:US
Mailing Address - Phone:917-330-3740
Mailing Address - Fax:
Practice Address - Street 1:14514 226TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-3534
Practice Address - Country:US
Practice Address - Phone:917-330-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY615517163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse