Provider Demographics
NPI:1225479637
Name:AGBOLA, VICTORIA OLUFUNMILOLA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:OLUFUNMILOLA
Last Name:AGBOLA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:O
Other - Last Name:AJAYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:502-775-1211
Mailing Address - Fax:502-443-9391
Practice Address - Street 1:2406 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1008
Practice Address - Country:US
Practice Address - Phone:502-775-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100263330Medicaid