Provider Demographics
NPI:1073914685
Name:IBIRONKE, AJIBOLA
Entity Type:Individual
Prefix:
First Name:AJIBOLA
Middle Name:
Last Name:IBIRONKE
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 1:3001 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1189
Mailing Address - Country:US
Mailing Address - Phone:301-618-2000
Mailing Address - Fax:
Practice Address - Street 1:3001 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1189
Practice Address - Country:US
Practice Address - Phone:301-618-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR186200363LA2100X
DCRN1016618163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN96444OtherCDS