Provider Demographics
NPI:1073920203
Name:AJIBOYE-LALA, OYERONKE O (NP)
Entity Type:Individual
Prefix:
First Name:OYERONKE
Middle Name:O
Last Name:AJIBOYE-LALA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 PEACHTREE PARKWAY
Mailing Address - Street 2:STE E #234
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:470-270-0730
Mailing Address - Fax:
Practice Address - Street 1:1701 N DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1019
Practice Address - Country:US
Practice Address - Phone:520-366-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11428363LP0808X
GARN201907363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner