Provider Demographics
NPI:1144567264
Name:BALOGUN, MOJISOLA R
Entity Type:Individual
Prefix:
First Name:MOJISOLA
Middle Name:R
Last Name:BALOGUN
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 1:9863 VISTA MEADOWS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5780
Mailing Address - Country:US
Mailing Address - Phone:702-327-0308
Mailing Address - Fax:
Practice Address - Street 1:5250 S RAINBOW BLVD UNIT 2008
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-0631
Practice Address - Country:US
Practice Address - Phone:702-327-0308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV810386363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily