Provider Demographics
NPI:1699919860
Name:AJAYI AJIBOLA, SIMBIAT O
Entity type:Individual
Prefix:
First Name:SIMBIAT
Middle Name:O
Last Name:AJAYI 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 1:17631 130TH AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-5823
Mailing Address - Country:US
Mailing Address - Phone:718-801-7581
Mailing Address - Fax:
Practice Address - Street 1:17631 130TH AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5823
Practice Address - Country:US
Practice Address - Phone:718-801-7581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY614041163W00000X
NYF307777363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse