Provider Demographics
NPI:1720892870
Name:AYISSOU, KODJO DJIMI
Entity type:Individual
Prefix:
First Name:KODJO
Middle Name:DJIMI
Last Name:AYISSOU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 N 187TH CT APT 101
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3244
Mailing Address - Country:US
Mailing Address - Phone:217-204-3285
Mailing Address - Fax:
Practice Address - Street 1:2990 N 187TH CT APT 101
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-3244
Practice Address - Country:US
Practice Address - Phone:217-204-3285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care