Provider Demographics
NPI:1265002075
Name:FAGBOLA, BAMIDELE ADEOYE (DNP, AGPCNP)
Entity Type:Individual
Prefix:DR
First Name:BAMIDELE
Middle Name:ADEOYE
Last Name:FAGBOLA
Suffix:
Gender:F
Credentials:DNP, AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:534 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5281
Practice Address - Country:US
Practice Address - Phone:508-973-7766
Practice Address - Fax:508-973-7753
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2301773363L00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner