Provider Demographics
NPI:1124577747
Name:POPOOLA, ABIMBOLA A (NP)
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:A
Last Name:POPOOLA
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 1:15211 VANOWEN ST
Mailing Address - Street 2:#209
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3606
Mailing Address - Country:US
Mailing Address - Phone:818-997-1888
Mailing Address - Fax:
Practice Address - Street 1:15211 VANOWEN ST
Practice Address - Street 2:#209
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3606
Practice Address - Country:US
Practice Address - Phone:818-997-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004175363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner