Provider Demographics
NPI:1083306617
Name:AJALA, PAULINE ABISOLA
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:ABISOLA
Last Name:AJALA
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 1:550 WRENHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6232
Mailing Address - Country:US
Mailing Address - Phone:678-622-4291
Mailing Address - Fax:
Practice Address - Street 1:550 WRENHAVEN CT
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6232
Practice Address - Country:US
Practice Address - Phone:678-622-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030081374376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide